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Family maiden name
Name husband
Name in your passport
First name
Gender
Marital status
Children Yes
No
Address
Zip-code
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
Zip-code of your GP
City of your GP
Phone number of your GP
Fax number of your GP
Email address of your GP
Occupation of your GP
Do you have high blood pressure? Yes
No
Do you have diabetes? Yes
No
For how long?
Did you have former operations? Yes
No
What kind of operations?
In which way was this surgery performed?

Open horizontal subcostal
Vertical
Laparascopic

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 sticking?
bandings / band-aid		 Yes
No
Do you suffer from sleeping apnoea? Yes
No
Do you have a psychiatric disease? Yes
No
What kind of psychiatric disease?
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 sigarettes 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 inhalator? 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 candy? No, I do not eat candy
I eat candy occasionally
I eat candy sometimes
I eat candy regularly
Do you eat chocolate candybars? 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 sugar added 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 chips and/or nuts? No, I do not eat chips and or nuts
I eat chips and or nuts occasionally
I eat chips and or nuts sometimes
I eat chips 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 preffered
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 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 After Care treatment? Yes, I want an After Care package
No, I do not want an After Care package
I will pay per visit
I don't know yet. Please inform me about the possibilities

Yes, I want an After Care Package
for the following term:		 Package for 6 months (Gastric Balloon)
Package for 1 year
Package for 3 years
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
between 8 and 4 pm:
How did you find us? By search engine
Through Private Healthcare
Through Big Matters
Through WLS
Through a website from a patient of EOC
Through a relation or a friend
Through my GP
Through which search engine? Google
MSN
Yahoo
Orange



 
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