Bariatric Patient Questionnaire

Secure form

This questionnaire helps the practice understand your goals, medical history and weight-loss surgery background before your appointment.

Full name Date of birth Email Phone Postcode

Your goals

Height Current weight Goal weight, if known What are your main goals for treatment?

Medical history

Previous weight-loss treatments or medications Previous abdominal surgery? Do you experience reflux or heartburn? Do you have diabetes? Do you have sleep apnoea?

Current details

Current medications Allergies Do you have a GP referral? Anything else you would like Dr Mastakov to know?

If your symptoms are urgent or changing, call the practice or seek urgent medical care.