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Obesity – Medical Weight Loss Questionnaire

Obesity is a multifactorial disease and requires an individualized approach and treatment. It is important to understand the nutritional, metabolic and psychological factors that lead to your increased weight, so that we can find out the best solution for your own case.

Please, complete this questionnaire form as accurately as possible.

EN – Ερωτηματολόγιο Παχυσαρκία – Ιατρική απώλεια βάρους










PHONES:






EMERGENCY CONTACT INFORMATION:



WEIGHT HISTORY



BODY TYPE IN:





ASSESSMENT OF DIETARY HABITS

What are the main factors that contribute most to weight gain and maintenance? For e.g. sweets/junk food, large quantities of food, constant snacking, bad mood, etc.





WEIGHT LOSS ATTEMPTS




PAST MEDICAL HISTORY (PMH)

PEDIATRIC MEDICAL HISTORY




ADULT PATIENT MEDICAL HISTORY

Please, note below any diseases that you suffer from, are being treated for or you have been hospitalized in the past.


FOR WOMEN





FOR MEN



PAST SURGICAL HISTORY

Describe the type of surgery, date, hospital and outcome – complications




MEDICATIONS

Please, note all medications that you are currently using and their dosages. Do not neglect to mention the medications that are not taken daily but only when symptoms are present.









ALLERGIES





FAMILY HISTORY

Is there a family history with significant medical conditions such as diabetes, heart disease, obesity, cancer, etc.?


Father:



Mother:



Brothers and Sisters:


SOCIAL HISTORY











GASTROINTESTINAL






CARDIOVASCULAR



RESPIRATORY





URINARY




NEUROLOGIC




MENTAL HEALTH





OTHER HISTORY DETAILS & COMMENS

INFORMED CONSENT INFORMATION