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Patient Questionnaire
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? When, did it work and for
Do you find time for regular physical activities? What kind of them?
Do you have any disease? (Name, if Yes)
Have you had any disease recently?
Do you take any medicines on regular basis? (If Yes, what type)
Have you taken any other medicines recently? (If Yes, what type)
Name(s) of any previous operations? (Date 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?
Do you have or have you ever had? Muscle disease, muscle weakness?
Yes
No
If yes, please describe
Heart or blood vesel problems?
Yes
No
If yes, please describe
Pulmonary and pipe disease (asthma, chronic bronchitis, pneumonia, tuberculosis, etc.)
Yes
No
If yes, please describe
Nerve system, diseases? (Meningitis, encephalitis, multiple sclerosis, Parkinson's disease, Epilepsy
Yes
No
If yes, please describe
Liverdiseases?
Yes
No
If yes, please describe
Eye diseases?
Yes
No
If yes, please describe
Articular diseases? (Rheumatism, polyarthitis)
Yes
No
If yes, please describe
Metabolic diseases? (Diabetes, thyroiddiseases)
Yes
No
If yes, please describe
Gastric and intestinal canal diseases? (Duodenal ulcer?)
Yes
No
If yes, please describe
Blood and fibrillation disorder?
Yes
No
If yes, please describe
Have any of your blood relatives have fibrillation disorder?
Yes
No
If yes, please describe
Allergy? (To medicaments, to household chemistry, to pollen, to food-products)
Yes
No
If yes, please describe
Do you have any other here not mentioned disease?
Yes
No
If yes, please describe
Do you smoke?
Yes
No
Do you wake up at nigh?
Yes
No
If yes, please describe
Do you ever had burning in oesophagus, stomach?
Yes
No
If yes, please describe
For woman - is there any possibility that you are pregnant?
Yes
No
Have you got Covid-19 vaccine / or have been infected? When?
Yes
No
If yes, please describe
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.
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Please make sure you mark all answers Yes or No