Please complete this form prior to your consults with your surgeon and dietitian.
* indicates mandatory fields

    * indicates mandatory fields

    First Name *

    Last Name *

    Date of Birth *

    Email *

    Section 1: Weight and Obesity Related Health

    Height (cm) *

    Current Weight (kg) *

    Heaviest Weight (kg) *

    How many years have you struggled with your weight? *

    What was the largest weight loss you achieved? *

    Weight loss attempts: *
    (Eg. Weight Watchers, Duromine, Keto, Intermittent Fasting etc.)

    Is there a family history of Diabetes? *

    Is there a family history of Heart Disease? *

    Do you have Diabetes? *

    Have you had Gestational Diabetes? *

    Do you suffer from reflux? *

    If you answered yes, how often do you experience reflux symptoms?

    Do you take any prescribed or over the counter (eg. Gaviscon, Mylanta) medications to treat your reflux symptoms? If yes, please list medications taken.

    Section 2: Diet

    Breakfast *
    (Please list 2-3 examples of a typical breakfast)

    Lunch *
    (Please list 2-3 examples of a typical breakfast)

    Dinner *
    (Please provide 2-3 typical dinner options and also list any desserts you might have.)

    Snacks *
    (Please list the types of food you graze or snack on between or after meals. Please also state when and how often you have these foods. Eg. nuts, fruit, cakes, biscuits, cheese, chips, lollies, chocolate.)

    Beverages *
    (Eg. soft drinks, energy drinks, alcohol. Please list what types and how often every day or week.)

    Take Away or Home Delivery *
    (What types and how often.)

    Section 3: Exercise

    Current Exercise *

    Exercise in the Past *

    Ability to engage in future exercise *
    (Please list any physical limitations.)

    Section 4: Social History

    Living Circumstances *
    (Eg. married, widowed, single, divorced, defacto)

    Employment Status/Occupation *
    (Eg. retired, working, studying. Please specify what type of work or study.)

    Do you have children? *
    (Please list number of children and age range.)

    Alcohol intake *
    (Please indicate quantity and frequency of beer, wine or spirits.)

    Smoking *
    (Please indicate quantity and frequency, if ceased - please indicate year.)

    Section 5: Medical History

    Previous Surgery *
    (Please list any previous surgery you have had.)

    Current Medical Problems *
    (Eg. Atrial Fibrillation, Hypertension, Diabetes, Kidney Dysfunction, Epilepsy, Asthma, Infertility, PCOS, Sleep Apnoea, Arthritis)

    Current Medical Treatments *
    (Please list all medications including tablets, patches, injectables – for diabetes and inhalers)

    Known Drug Allergies

    Final Section: Goals

    Please list what you wish to achieve *
    (Eg. improved health, control or cure diabetes, better physical function, ability to attend to self care.)

    Please only click submit once, it may take a minute to complete the submission process.

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