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Surname Mr.
Mrs. 		Miss
Ms.
Surname
First name
Gender
Marital status
Children Yes
No
If yes, how many?   
Address
Postcode
City
Country
Date of birth
Telephone home
Telephone work
Mobile phone
Email home
Email work
Emergency contact 1
Relationship with emergency contact 1
Phone number emergency contact 1
Emergency contact 2
Relationship with emergency contact 2
Phone number emergency contact 2
Height ft inch
Weight stones pounds
Your BMI
Does obesity occur in your family? Yes
No
Name of your GP
Address of your GP
Postcode of your GP
City of your GP
Phone number of your GP
Fax number of your GP
Email address of your GP
Do you have high blood pressure? Yes
No
Do you have diabetes? Yes
No
For how long?
Have you had any previous operations? Yes
No
What kind of operations?
In which way was this surgery performed?

Open horizontal subcostal
Vertical
Laparascopic

Have you had general anaestethic?
Are you allergic to medication? Yes
No
What kind of medication?
Do you suffer from blood clotting? Yes
No
Are you allergic to iodine? Yes
No
Are you allergic to latex or plasters? Yes
No
Do you suffer from sleep apnoea? Yes
No
Have you had psychiatric treatment? Yes
No
What kind of treatment?
Did you have a psychiatric
stay in a hospital or clinic?		 Yes
No
When was this psychiatric stay
in a hospital or clinic?
Are you still under psychiatric control? Yes
No
Do you have approval
from your psychiatrist?		 Yes
No
Do you have lung embolia? Yes
No
Do you use a CPAP machine? Yes
No
When do you use your CPAP machine? During day-time
During night-time
Both day and night
Do you use oxygen? Yes
No
Do you smoke? Yes
No
How many cigarettes a day?
If not, did you smoke before? Yes
No
When did you stop smoking?
Do you have asthma? Yes
No
Do you use an inhalor? Yes
No
Do you have bronchites? Yes
No
Do you use drugs? Yes
No
Did you use drugs before? Yes
No
When did you stop using drugs?
Do you have stomach problems? Yes
No
Do you have reflux problems? Yes
No
Do you use aspirin? Yes
No
What is the reason for your overweight? I'm a sweet tooth
I'm used to eating big meals
I'm a sweeth tooth and I eat big meals
Do you excercise or fitness? No, I do not excercise
I excercise occasionally
I excercise sometimes
I excercise regularly
Your former diet attempts: With dietician
With WeightWatchers
With Atkins diet
With SlimFast
With medication
With an intragastric balloon
What is your eating pattern? I eat meals regularly
I do not eat meals regularly
I'm an emotional eater
Do you drink alchohol? Daily
Weekly
Little
No
Number of units per week:
Do you eat sweets? No, I do not eat candy
I eat candy occasionally
I eat candy sometimes
I eat candy regularly
Do you eat chocolatebars? No, I do not eat chocolate or candybars
I eat chocolate or candybars occasionally
I eat chocolate or candybars sometimes
I eat chocolate or candybars regularly
Do you eat cookies? No, I do not eat cookies
I eat cookies occasionally
I eat cookies sometimes
I eat cookies regularly
Do you drink added sugar softdrinks? No, I do not drink sugar added softdrinks
I drink sugar added softdrinks occasionally
I drink sugar added softdrinks sometimes
I drink sugar added softdrinks regularly
Do you add sugar to
meals and/or drinks?		 No, I do not add sugar to meals and/or drinks
I add sugar to meals and/or drinks occasionally
I add sugar to meals and/or drinks sometimes
I add sugar to meals and/or drinks regularly
Do you eat crisps and/or nuts? No, I do not eat crisps and or nuts
I eat crisps and or nuts occasionally
I eat crisps and or nuts sometimes
I eat crisps and or nuts regularly
Are you under control of a specialist? Yes
No
What kind of specialist?
Do you use medication? Yes
No
What is the name of this medication
and what is the quantity you use?
What do you use medication for?
Important other medical information:
What is your preferred
payment method?		 I will pay cash in Euros
I will make a bank transfer
I will pay by credit card
Your preferred surgery type: I prefer the Gastric Band
I prefer the Roux-en-Y Bypass
I prefer the Open Bypass
I prefer the Gastric Balloon
I prefer the Mc Lean
I prefer the Vertical Gastrectomy (Sleeve)
Information for our medical consultant
before surgery:
Have you been hospitalized recently? Yes
No
Are you working in the
food processing industry?		 Yes
No
Do you plan to get aftercare treatment? Yes, I want an aftercare package
No, I do not want an aftercare package
I will pay per visit
I don't know yet. Please inform me about the possibilities

Yes, I want an aftercare Package
for the following term:		 Package for 6 months (Gastric Balloon)
Package for 1 year
In which way do you plan to travel
to the hospital?		 I will travel by Airplane
I will travel by Eurostar
I have the following
surgery date preference:		 I want my surgery booked at the first possible option
I want my surgery booked at a specific date
Exact preferred surgery date:
For the booking, please contact me by: Phone
Email

I need more information, please contact me by:

 Phone
Email
Contact me on this phone number:
Preferred contact time: Morning
Afternoon
Evening

How did you find us? By search engine
Private Healthcare
Big Matters
WLS Group
Website from a patient of EOC
Relation or a friend
Through my GP
Through which search engine? Google
MSN
Yahoo
Orange
Other:



 
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