WLS Eligibility Assessment

Full Name (as per your passport):*
Date of birth:*
Email :
Mobile :
Next of kin:
Next of Kin Phone number:
Gender/Sex:*MaleFemaleOther
Country of Residence:*
Weight :*
Height :*

How long have you been this weight?*
When did your weight gain start (eg. 7 years ago)?*
Have you tried diet and exercise to lose weight?*YesNo
Do you regularly eat confectionery, cakes or take away foods?*YesNo
Which best describes your daily diet:*Higher Carbohydrate dietHigher protein diet50/50 carbs to protein

Do you prefer? *Sweet foodsSavoury foodsI enjoy both
I am active: *Not at allOccasionallyVery active
Are you a smoker? *NoYes
How often do you drink alcohol? *OccasionallyWeeklyDaily
Have you had any surgical procedures in the past? *YesNo

Are you currently taking any medications including blood thinners or aspirin? * YesNo

Do you have a history or currently suffer from any of the below:*
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
Other

Family Medical History* AsthmaCancerHeart DiseaseHigh Blood PressureHypertensionNone of the above
Have you or are you currently receiving treatment for any of the following ? *
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

Why are you considering Gastric Surgery *

Surgery type preference *
Gastric SleeveGastric bypassMini Gastric BypassGastric Sleeve with Minimiser ringPrefer Surgeons RecommendationNot sure
Your name*

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