Medical Questionnaire

Please carefully complete the medical questionnaire below, answering all questions, in order that we can process your requirements. Thank you. (Completion of this questionnaire will take approx 1 to 2 minutes).

Full Name

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Address
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Phone
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Mobile
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E-Mail
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Date of Birth
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Sex
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Procedure required - please give details of the procedure that you would like to be carried out. If you are not sure one of our advisors will let you know whether you are best suited to the Gastric Band or Gastric Balloon:

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Please answer the following questions:

Have you been diagnosed with Hepatitis A,B or C ?
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Are you HIV positive ?
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Do you smoke ?
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How many per day ?
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Have you had any serious illness, disease or injury ?
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If yes please provide details:

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Have you previously undergone any operations with a general anaesthetic ?
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If yes please provide details:

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Are you currently taking any prescribed medication ?
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If yes please provide details:

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Are you being treated for any illness or disease ?
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If yes please provide details:

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Are you allergic to any drugs ?
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If yes please provide details:

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Do you suffer from any of the following conditions ?

High blood pressure ?
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Heart palpitations ?
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Diabetes ?
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Blood clotting problems ?
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Heart disease ?
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Breathing or Lung problems ?
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Over-active thyroid ?
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Under-active thyroid ?
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Breast problems ?
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If yes please give us details to any other conditions you have had:

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Please answer the following:

What is your age ?
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What is your height ?
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What is your weight ?
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Do you lead a healthy lifestyle ?
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Do you take regular excercise ?
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Are you pregnant or planning to be in next 6 months ?
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Are you taking any hormonal contraception or HRT replacement?
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If yes please specify what drug and the reason for taking:

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This document is strictly confidential and is for clinical use only. It is important that you are factual and accurate in your completion of your medial questionnaire, in order that we can serve you quickly, safely and efficently. Thank you!

ADDITIONAL INFORMATION

(Please also complete this section)

Procedure wished
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Which airport you would prefer to fly from ?
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Which date would best suit you for surgery ?
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You must agree to our terms and conditions to proceed.