Medical History
Full Name
*
First Name
Last Name
What is your Gender?
*
Male
Female
Birth Date
-
Month
-
Day
Year
Date
Email
[email protected]
Confirm Email
[email protected]
mobile
*
-
country code
mobile number without the 0 eg; 420888777
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
nationality
AUSTRALIAN/EUROPEAN
ABORIGINAL/TORES STRAIT ISLANDER
PACIFIC ISLANDS
ASIAN
SUB CONTINENTAL
OTHER
About you weight and body
Please be as honest as possible.
Height in cms
*
CURRENT WEIGHT
*
REQUIRED WHEN CALCULATING BMI.
Your waist measurements in cm
*
Upload photos
Photos will only be provided to medical & customer service staff as part of your assessment.
Please upload a recent full body (clothed) front facing photo
*
Browse Files
Images should be in a valid format such as, jpeg, .jpg or .gif
Cancel
of
Please upload a recent full body (clothed) side facing photo
*
Browse Files
Images should be in a valid format such as, jpeg, .jpg or .gif
Cancel
of
Please upload a recent photo of your face
*
Browse Files
Images should be in a valid format such as, jpeg, .jpg or .gif
Cancel
of
How long have you been at this weight?
fluctuations of +/- 10kg during this time is acceptable
When did your weight gain start?
eg; 2 yrs ago
Do you regularly crave sweet foods or high carbohydrate foods
Yes
No
What are your normal eating habits?
Higher carbohydrate diet
Higher protein diet
50/50 carbohydrate/protein diet
Do you prefer?
Sweet food
Savoury food
Both
Have you tried diet/exercise in the past to help with wieghtloss?
Yes
No
What is your activity level?
Sedentry
Moderately active
Very active
Medical History
For the surgeon to select the best procedure for you, it is important that all answers are accurate and honest. It is imperative that you disclose all medical conditions/treatments that you have had in the past or present. If it is in your medical history then you should enclose it. If a condition is not listed below, please select other and provide details.
Check the conditions that apply to you:
*
Adrenal Insufficency
Anemia
Asthma
back injury/problem
Bleeding
Blood clots
Breathing problems
Cancer
Cardiac disease
Deep vein thrombosis
Diabete
Epilepsy
Fatty liver
Food allergies
Gallstones
Heart burn
Heart disease
High blood pression
Hypertension
Psychiatric disorderAdrenal Insufficency
Hepatitis
HIV
Hyperthyroidism
Hypothyroidism
Kidney disease
pulmonary embolism
reaction to anaesthetics
Respiratory conditions
Scar tissue problems
Skin conditions
Sleep apnea
sleep disturbance issues
Stomach issues
Stroke
Underlying disease
Uper gastric problems
Varicose veins
no conditions or treatments in past
Other
Are you currently experiencing any of the following?
*
Chest pain
Respiratory
Cardiac disease
Cardiovascular
Hematological
Lymphatic
Neurological
Psychiatric
Gastrointestinal
Genitourinary
Weight gain
Weight loss
Musculoskeletal
Other
Please list all surgeries you have had in the past with date and procedure.
Are you currently taking any medications?
*
Yes
No
Please list all medication you take on a regular basis, including herbal suppliments?
Do you have any medication allergies or allergies to food?
*
Yes
No
Not Sure
If yes, please list all allergies.
How would you rate your overall fitness?
1
2
3
4
5
1 being poor 5 being optimal
How would you rate your overall health?
1
2
3
4
5
1 being poor 5 being optimal
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Next
Is there a family history of any of the following?
Asthma
Cancer
Diabetes
Hypertension
High blood presure
none
Other
Please let us know if you have in the past or currently, receiving treatment for any of the following mental health conditions
Alcohol, other substance abuse or addiction issues
Anxiety, including generalised anxiety, panic attacks or phobias
Depression, including major depression, post-operative depression and dysthymia
Eating disorder, including anorexia nervosa, bulimia
Manic depressive illness, including bi-polardisorder
Post-traumatic stress disorder
Psychiatric illness
Schizophrenia or any other psychotic disorder
Stress, insomnia, chronic tiredness
None
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
used to
If yes, how many per day do you smoke/when did you quit?
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
For how long and what type of illicit drug?
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Please let us know why you are considering gastric surgery.
*
Let us know in a sentence or two
Is your family aware and supportive of you undertaking this procedure.
Family aware and supportive
Family aware but not supportive
Family not aware
Surgery type preference If you have researched and have a preference or preferences, please select all that apply.
Gastric Sleeve
Gastric Bypass
Mini Gastric Bypass
Gastric Sleeve with Minimiser Ring
Unsure at this stage
Do you have a current passport with a minimum of 6months before it expires from the date of surgery?
YES
NO
If you are eligible, do you wish to be fast-tracked?
YES
NO
Fast Tracked is usually within the next 21 days. We hold open surgery spaces for patients who wish to go as soon as possible. If you select YES, we will provide you both a fast-track and normal quote.
When is your preferred date to have the procedure completed?
-
Month
-
Day
Year
Date
Declaration
Type a question
I have read and agreed to Total Body Reformation's term and conditions
I am considering this procedure of my own free will and am not being forced or coerced
The information I have provided is true and correct to the best of my knowledge
How did you hear abou us?
Facebook
Google
Other search engine
Other
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