Health Questionnaire

Do you currently suffer from any of the following conditions?

Other (please specify):

Do you take any medicines regularly?

Yes No

If yes (please list them):

Have you had any surgeries before?

Yes No

If yes (what kind and when):

Do you suffer from heartburn?

Yes No

Do you have any known allergies?

Yes No

If yes (please specify):

Do you smoke?

Yes No

Have you tried to manage your weight through a balanced, healthy diet?

Yes No

If yes (when, did it work, and how long):

Do you find time for regular physical activity?

Yes No

If yes (what type and how often):

Describe your typical eating routine...

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

Yes No

With this questionnaire we collect data in order to provide professional, information based medical advise. The personal data of the person will be used only for informational purpose for the Sigulda Hospital ("Siguldas slimnica" Ltd, registration number 40003124730) bariatric team, related to the potential performance of the medical treatment.

Health Questionnaire

Weight Loss Latvia – Health Questionnaire

Personal Information

Physical Information

Medical History

Lifestyle & Habits

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