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 Please list your past surgeries. Are you currently taking any medications including blood thinners or aspirin? * YesNo Please list each medication and dosage. 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* yesBy submitting this form you agree to our terms and conditions in our Privacy Policy.* Please attach full body front facing clothed photo. Ensure the file name has no spaces in it. * Please leave this field empty. Math Captcha + 47 = 56