Patient Questionnaire

Full name

Date of birth

Email

Phone

Country & City

Current weight

Height

BMI

What is your profession, work environment, stress level?

How does your daily ‘eating routine’ approximately look like?

Have you tried to manage your weight with balanced, regular, healthy diet? Have you tried to manage your weight with balanced, regular, healthy diet? When, did it work and for how long?

Do you find time for regular physical activities? What kind of them?

Do you suffer from any disease? Do you suffer from any disease (Metabolic, pulmonary, heart, liver, nerve, muscle, gastric any other)? (Name, if Yes)

Do you take any medicines on regular basis? (If Yes, what type)

Name(s) of any previous operations? (Year performed)

Have you or any blood relative had any complications due to a previous anaesthetics?

Have you ever had blood transfusion? Did you have any complications?

Allergy? (To medicaments, to household chemistry, to pollen, to food-products)

Do you smoke?

Yes

No

Have you ever had burning in oesophagus, stomach?

For women – Is there any possibility that you are pregnant?

Have you got Covid-19 vaccine / or have been infected? When?

Privacy information. This personal information is collected and used only to provide you the best possible medical care and will not be spreaded to the third persons not involved in your medical treatment.

Patient Questionnaire, v2.0

Our site use cookies