Bariatric Patient Questionnaire

Dr Mikhail Mastakov MD, FRACS
Weight Loss and General Surgery

Please complete this questionnaire before your weight-loss surgery appointment. It helps the practice understand your medical history, weight-loss background and goals so your consultation can be planned appropriately.

Clinics: Sunnybank, Cleveland, Hervey Bay and Gold Coast
Phone: 07 3414 3950 | 07 4148 7082 | 0491 688 212
Email: admin@mastakovsurgery.com

Title *

First Name *

Family Name *

Date of Birth *

Gender *

Occupation

Address - Street Address *

Address - City *

Address - State / Province / Region *

Address - ZIP / Postal Code *

Email Address *

Contact Phone Number *

Next of Kin

Contact Phone Number

Medicare No.

Reference No.

Private Health Fund

Membership No.

COVID Vaccination Information *

Unvaccinated1 Dose OnlyFully Vaccinated (2-3 Doses)

Please specify

3. Weight Loss History:

Current weight (kg) : *

Height (cm) : *

BMI (Dr Mastakov to complete):

Heaviest weight (kg) : *

Lowest weight (kg) : *

Onset of Obesity *

ChildhoodAdolescenceAdulthood

Have you tried to lose weight in the past? *

YesNoNot Sure

If Yes please list below:

4. Current Doctors: *

Do you have a specialist/s whom you attend? *

YesNoNot Sure

Do you give consent for us to obtain your medical history from these Specialists? *

YesNo

If Yes please list below:

5. Current Medication/s: *

Do you take any Contraceptive medications (female)? *

YesNoNot Sure

Do you take any Blood Thinners or Anti-Clotting medications? *

YesNoNot Sure

Please Specify

6. Surgical History: *

7. Medical History:

Coronary Heart Disease? *

YesNoNot Sure

Chest pain? *

YesNoNot Sure

Heart Attack or Angina? *

YesNoNot Sure

High Cholesterol? *

YesNoNot Sure

High Blood Pressure or Hypertension? *

YesNoNot Sure

Irregular heart beat or Atrial Fibrillation? *

YesNoNot Sure

Breathing problems or shortness of breath? *

YesNoNot Sure

Anaemia (low red cell count)? *

YesNoNot Sure

Stroke? *

YesNoNot Sure

Asthma or COPD? *

YesNoNot Sure

Chronic cough? *

YesNoNot Sure

Sleep Apnoea? *

YesNoNot Sure

Diabetes? *

YesNoNot Sure

Neuropathy or numb feet? *

YesNoNot Sure

Vision problems? *

YesNoNot Sure

Thyroid Disease? *

YesNoNot Sure

Seizures or Epilepsy? *

YesNoNot Sure

Migraines? *

YesNoNot Sure

Bleeding Disorder? *

YesNoNot Sure

Blood clots or DVT? *

YesNoNot Sure

Arthritis? *

YesNoNot Sure

Chronic back pain? *

YesNoNot Sure

Autoimmune Disease?

YesNoNot Sure

Fractures or Osteoporosis? *

YesNoNot Sure

Reflux or Heart Burn? *

YesNoNot Sure

Fatty Liver? *

YesNoNot Sure

Abnormal liver blood cells? *

YesNoNot Sure

Cirrhosis of the liver? *

YesNoNot Sure

Bowel Cancer or Polyps? *

YesNoNot Sure

Hepatitis? *

YesNoNot Sure

Irritable Bowel Syndrome? *

YesNoNot Sure

Infertility? *

YesNoNot Sure

Chronic nausea or vomiting? *

YesNoNot Sure

PCOS (females): Polycystic Ovary Syndrome? *

YesNoNot Sure

Kidney Stones? *

YesNoNot Sure

Kidney Disease? *

YesNoNot Sure

Urine Incontinence? *

YesNoNot Sure

Prostate Enlargement (males)? *

YesNoNot Sure

Recurrent Urinary Infections? *

YesNoNot Sure

Other:

If Yes to Diabetes:

Home finger prick testing – Usually under 10mmon/L *

YesNoNot Sure

Last Hba1c result on blood tests higher than 8.0% *

YesNoNot Sure

Family history of Cancer or Heart Attack before 55 years of age: *

YesNoNot Sure

Developmental history of traumatic life event/s such as abuse, loss or neglect that might affect your goals for weight loss or your ability to cope after surgery: *

YesNoNot Sure

8. Smoking History:

Are you a Current smoker? *

YesNo

Are you a Past smoker? *

YesNo

Are the years you smoked all together greater than 10? *

YesNoNot sure

9. Alcohol History:

Alcohol History: Current average alcohol intake per week: *

Past alcohol abuse or dependency: *

YesNoNot Sure

10. Use of Recreational Drugs History: Current recreational drugs abuse or dependency: *

YesNoNot Sure

Past recreational drugs abuse or dependency: *

YesNoNot Sure

11. Psychiatric or Mental Illness History:

Depression

Year of Onset

Specialist/ Psychiatrist/ Psychologist

Controlled?

YesNoNot Sure

When was it last reviewed?

Anxiety

Year of Onset

Specialist/ Psychiatrist/ Psychologist

Controlled?

YesNoNot Sure

When was it last reviewed?

ADHD

Year of Onset

Specialist/ Psychiatrist/ Psychologist

Controlled?

YesNoNot Sure

When was it last reviewed?

Bipolar Disorder

Year of Onset

Specialist/ Psychiatrist/ Psychologist

Controlled?

YesNoNot Sure

When was it last reviewed?

Eating Disorder

Type

Year of Onset

Specialist/ Psychiatrist/ Psychologist

Controlled?

YesNoNot Sure

When was it last reviewed?

Other:

Have you ever been diagnosed with:

Year of Onset

Specialist/ Psychiatrist/ Psychologist

Controlled?

YesNoNot Sure

When was it last reviewed?

Have you ever been diagnosed with:

Year of Onset

Specialist/ Psychiatrist/ Psychologist

Controlled?

YesNoNot Sure

When was it last reviewed?

12. Allergies:: *

13. Exercise Tolerance:

How far can you walk on a flat surface? *

MetersUnlimitedUnsure

Please Specify Number Per Meter:

When you need to stop is this normally due to?

Trouble BreathingPainFatigueOther

Please Specify

14.. Investigation History:

Blood Tests *

YesNoNot sure