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Taking the time to fill out this form helps the medical team better understand your situation which in turn helps you get the most out of your consultation.

STEP 1 of 5

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29/11/2023

NAME, SURNAME*

Please type your full name.

EMAIL*

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PHONE*

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AGE*

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SELECT GENDER*

FemaleMale

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CALCULATE YOUR BMI*

ImperialMetric

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Weight (St)

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Weight (lbs)

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Height (Ft)

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Height (in)

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Weight (Kilograms)

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Height (Centimeters)

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BMI

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DO YOU HAVE ANY CHRONIC OR ACUTE DISEASES ESPECIALLY ANY CONNECTED WITH BEING OVERWEIGHT?

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ARTERIAL HYPERTENSION (ELEVATED BLOOD PRESSURE)*

YesNo

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ANY FORM OF ARTHITIS*

YesNo

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DIABETES*

YesNo

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GASTRO OESOPHAGEAL REFLUX SYNDROME (HEARTBURN / FREQUENT BELCHING)*

YesNo

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DO YOU HAVE NOW OR DID YOU HAVE IN THE PAST ANY PSYCHIATRIC DISEASE?*

YesNo

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HAVE YOU EVER HAD ANY SURGICAL PROCEDURES? IF YES WHAT PROCEDURES?*

YesNo

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ADDITIONAL INFORMATION

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DO YOU HAVE ANY ALLERGIES?*

YesNo

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DO YOU HAVE AN ALLERGY TO ANY MEDICATION? IF YES WHAT REACTION HAVE YOU HAD IN THE PAST?*

YesNo

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ADDITIONAL INFORMATION

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DO YOU USE ANY MEDICATIONS ON A REGULAR BASIS? IF YES WHAT KIND?*

YesNo

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ADDITIONAL INFORMATION

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ARE YOU CURRENTLY ON ANY BLOOD THINNING MEDICATIONS?*

YesNo

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HAVE YOU EVER HAD A BLOOD TRANSFUSION?*

YesNo

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ANY OTHER INFORMATION THAT YOU THINK MAY BE RELEVANT.

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