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Emporium Wellness

Patient Questionnaire

Please fill out the form below to know about your medical history

    PERSONAL DATA

    Name:

    Last Name:

    E-mail:

    Telephone No: (Home):

    (Business):

    (Mobile):

    Address:

    City:

    State:

    Zip Code:

    Date Of Birth:

    Age:

    Ocupation:

    Prospective Surgery Date:

    Patient Coordinator:

    CONTACT PERSONS

    Name:

    Relationship:

    Address:

    Telephone Home:

    Telephone Bus:

    FAMILY STRUCTURE

    Marriage status:

    Name of Partner Spouse:

    Children/Ages:

    WEIGHT HISTORY

    Min Weight in Adulthood:

    Max Weight in Adulthood:

    Current Weight:

    Height:

    BMI:

    WEIGHT LOSS HISTORY

    Appetite suppressants:

    Duration:

    Any other drug treatment:

    Duration:

    FAMILY MEDICAL HISTORY

    Details of any other weight loss measures:

    Was there any particular event that lead to significant weight gain:

    Allergies:

    Alcohol:

    Do you smoke?:

    Have you smoked in the past?:

    Do you take multivitamin tablets or other dietary supplements?:

    LADIES

    Do you have regular periods (26 - 33 days):

    Do have problems with excessively heavy periods:

    SURGICAL HISTORY

    Please give details of any past operations:

    PERSONAL MEDICAL HISTORY

    Diabetes:

    Asthma:

    Respiratory:

    Arthritis:

    Back Pain:

    Kidney or urinary disorder:

    Neurological:

    Psychological/nervous disorder:

    Gallstones:

    Reflux or heartburn:

    Gastric or duodenal ulcer:

    Hepatitis or liver disease:

    High blood pressure:

    Heart disease:

    High cholesterol:

    Anaemia or bleeding disorder:

    Thrombosis or clotting disorder:

    Varicose veins or leg swelling:

    Eczema or skin condition:

    Hayfever or Rhinitis:

    Please give details of any major illnesses/problems:

    MEDICATIONS

    Medication for psychiatric disorder:

    Migraine medication:

    Medications to assist weight loss:

    Drugs for epilepsy:

    Drugs for asthma or breathing:

    Hormones:

    Cortisone:

    GASTRO ESOPHAGEAL REFLUX / INDIGESTION

    Do you have a history of heartburn or indigestion:

    Do you suffer heart burn / indigestion during the night?:

    What aggravates or causes your reflux?:

    Do you have difficulty swallowing:

    Does food ever get stuck:

    Does food or fluid reflux into the mouth:

    Do you vomit with reflux:

    Do you suffer from recurrent sore throats:

    Do you suffer from a hoarse voice:

    CONTACT INFORMATION

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