WLS Eligibility Assessment

WLS Eligibility Assessment

















    Sweet foodsSavoury foodsI enjoy both
    Not at allOccasionallyVery active
    NoYes
    OccasionallyWeeklyDaily
    YesNo


    YesNo



    Adrenal InsufficiencyAnemiaAsthmaBack Injury/problemsBleeding tendencyBlood ClotsBreathing ProblemsCancerCardiovascular AccidentsDeep vein thrombosisDiabetesEar nose and throat issuesEpilepsyFatty LiverFood AllergiesGallstonesHave you fallen Asleep Whilst DrivingHeart BurnHeart diseaseHepatitisHigh Blood PressureHIVHypertensionKeloid ScarringKidney disease / issuesOesophageal SymptomsOesophagitisPulmonary embolismReaction to AnaestheticsRespiratory ProblemsScar Tissue ProblemsSkin IssuesSleep ApneaStomach IssuesUpper Abdominal PainVaricose VeinsNone of the above

    AsthmaCancerHeart DiseaseHigh Blood PressureHypertensionNone of the above

    Anxiety, panic attacks or phobia’sAlcohol or drug addictionDepression, post operative depression and dysthymiaEating disorder – Anorexia nervosa or bulimiaManic depressive illness including bi polar disorderPost traumatic stress disorderPsychiatric illnessSchizophrenia or any other psychotic disordersStress, insomnia, chronic tirednessNone of the above

    Aware & SupportiveAware & not supportiveNot Aware



    Gastric SleeveGastric bypassMini Gastric BypassGastric Sleeve with Minimiser ringPrefer Surgeons RecommendationNot sure

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