Weight Loss Riga Health Questionnaire

STEP 1 of 6

16.67%

HEALTH ASSESSMENT

20%

Age*

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Select gender*

Female Male

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Choose your measurement*

Imperial Metric

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Your weight

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Your height

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Your BMI

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“2 years ago I decided to have a gastric bypass, best decision I've ever made. Over 8 stone loss so far”

Stuart | Gastric Bypass

YOUR HEALTH

80%

Did you previously or currently have any psychiatric diseases?*

Yes No

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Please provide more information*

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Have you ever had any surgical procedures?*

Yes No

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Please provide more information*

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Do you have any allergies? (including allergic reactions to medications)*

Yes No

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Please provide more information*

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“11 months in and over 9 stone gone forever, from a size 24+ to a size 8-10”

Charmaine | Gastric Bypass

YOUR HEALTH

95%

Do you use any medications on a regular basis?*

Yes No

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Please provide more information*

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Are you currently on any blood thinning medications?*

Yes No

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Please provide more information*

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Have you ever had a blood transfusion?*

Yes No

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Any other information that you think may be relevant?

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“10 months post-sleeve. 4 stone down. Diabetes gone. Joint pain gone. Asthma gone. Feeling great at 48”

Kathryn | Gastric Sleeve

ABOUT YOU

100%

Name*

Please type your full name.

Email*

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Phone number*

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“You’re one step away from starting your journey to lasting weight loss success”

Mim | Patient Coordinator