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Bariatric Referral





Please fill out all the questions to the best of your knowledge, if you don’t know the answer, simply put DON’T KNOW. The form will be viewed by one of our bariatric practitioners shortly.

PATIENT DETAILS

Name

Address

Telephone

Email

Date of Birth

Marital Status

Occupation

Hospital Number

REFERRING GP

Name

Practice Name

Address

Telephone

Fax

CURRENT STATISTICS

Height (in cm)

Weight (in kg)

BMI

Blood Pressure

Lipid Screen (HDL, LDL)

Diabetes Screen

Endocrine Screen (TFTs, cortisol)

MEDICAL HISTORY

Does the patient suffer from any of the following? If so, please give details of investigation results and current treatments:

Angina

Asthma

Arthritis

Diabetes

Epilepsy/seizures

Gallbladder disease

Gynecological disease or menstrual irregularities

Heartburn/reflux

Heart disease

Hiatus hernia

High cholesterol

Hypertension

Joint pains

Psychiatric illness

Renal disease

Serious injury

Sleep apnoea/snoring

Stroke

Thyroid disorders

Other

CURRENT MEDICATIONS

Please list medication name(s) and dosage(s):

PREVIOUS SURGERY

Please list date(s) and surgery details:

PREVIOUS MAJOR ILLNESSES NOT REQUIRING SURGERY

Please list date(s) and illness(es) details:

SMOKING AND ALCOHOL INTAKE

Do you smoke?
 Yes No Ex-smoker

If smoker, how many do you smoke a day?

If ex-smoker, how long ago did you quit?

Alcohol units consumed per week

EATING PATTERNS

´┐╝Please describe any abnormal eating patterns including binging, bulimia, compulsive overeating, excessive sweet tooth etc.

WEIGHT LOSS HISTORY

Please give details of all periods of weight loss including (1) duration of weight loss activity, (2) method (e.g. diet followed, medication, exercise plan) and (3) results:

What was your highest adult weight and in what year?

What was your lowest adult weight and in what year?

FAMILY HISTORY

´┐╝Are other family members obese or suffering from eating disorders? Do immediate family members suffer from obesity co-morbidities such as diabetes, heart disease, hypertension?

MOTIVATION

What is the patient’s motivation for this surgery?

Does the patient understand need for long-term follow up? Are they willing to adhere to the recommended diet and other commitments required following surgery (re alcohol and tobacco intake, exercise, keeping scheduled appointments etc)?

ADDITIONAL INFORMATION

Additional information may be provided here or in a supporting letter.

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