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New Patient Registration(Bariatric) & Medical History

New Patient Registration(Bariatric) & Medical HistoryRana Barakat2025-07-27T11:29:09+10:00

Bariatric Patient Registration & Medical History

Please complete this form before your first bariatric consultation to help us understand your health background and support your care.

"*" indicates required fields

Step 1 of 5

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Personal Details

Title*

MRS

MISS

MASTER

Name*

First Last

Date of Birth*

Day

Month

Year

Residental Address*

Street Suburb Postcode

Phone Number

Mobile*

Email*

Other Details

Medicare and Concession

You are:

Insured

Uninsured

Health Funds & Insurance Health Fund Name *

Fund number

Reference

Expiry

Medicare number*

Reference*

Expiry*

Pension card (if applicable)

Expiry

Health Care card (if applicable)

Expiry

DVA VETERNAN AFFAIRS card (if applicable)

GOLD

WHITE

ORANGE

DVA Card Number

Medical History

Medical History: Please indicate any medical conditions that you currently have or have been diagnosed with:

Select All

Type 2 Diabetes

High Cholesterol / Dyslipidemia

Hypertension (High Blood Pressure)

Sleep Apnea

Gastroesophageal Reflux Disease (GERD)

Asthma

Cardiovascular Disease

Stroke

Thyroid Disease

Liver Disease

Osteoarthritis

Depression / Anxiety

Kidney Disease / Chronic Kidney Disease (CKD

Anemia / Iron Deficiency

Smoking History / Nicotine Use

Previous Abdominal Surgery

Malignancy / Cancer History

Alcohol Use Disorder

Polycystic Ovary Syndrome (PCOS)

Other

Weight (kg)

Please enter a number from 0 to 2000.

Height (cm)

Please enter a number from 0 to 300.

What was your highest weight? (kg)

How many years have you struggled with your weight

Please enter a number from 0 to 100.

Have you tried weight loss programs before?

Yes

If yes, please specify which ones and the duration

Have you previously had any weight loss surgery

Yes

If yes, please specify the type of surgery and year

Please list any surgeries you have had in the past, including this year:

Any complications from pervious surgeries?

Yes

If yes, please explain

Please list any medications you are currently taking, including over-the-counter drugs, supplements, and vitamins and dosage:

Do you take any blood thinners?

Yes

Do you take any weight loss medication?

Yes

If yes, please specify:

Lifestyle and Habits: Do you smoke

Yes

If yes, how many cigarettes per day?

Do you use nicotine in any other form? (e.g., vaping, cigars)

Yes

If yes, please specify:

Do you drink alcohol?

Yes

If yes, how often?

Daily

Weekly

Monthly

Rarely

How many caffeinated drinks (coffee, soft drinks, etc) do you consume per day?

Have you had any pervious history of substance abuse or addiction?

Yes

If yes, please explain

Exercise Habits (check all that apply)

None

Light Exercise (e.g., Walking, Stretching)

Moderate Exercise (e.g., jogging, cycling)

Intense Exercise (e.g., running, weightlifting)

Average hours of sleep you get per night?

Please enter a number from 0 to 24.

Do you experience stress or emotional eating

Yes

If yes, please explain

Mental Health: Do you have a history of depression or anxiety?

Yes

If yes, have you been treated for it?

Yes

Treatment type (medications, therapy, etc)

Have you ever been diagnosed with an eating disorder (e.g., binge eating or bulimia)?

Yes

Are you currently seeing a psychologist or counsellor?

Yes

Do you have a support system in place (friends, family, etc) to help you through your weight loss surgery?

Yes

What are your primary reasons for considering bariatric surgery

Improve overall health

Improve quality of life

Manage or eliminate Type 2 Diabetes

Manage or eliminate Sleep Apnea

Have you ever had a consultation with a bariatric surgeon before?

Yes

If yes, what was the outcome?

General Practitioner Details

A referral is required to see the specialist.

Name of doctor

Location of medical centre

Street Suburb Postcode

Phone

Fax

Do you have a referral letter?

Please attach Referral if applicable

Max. file size: 64 MB.

A GP referral is required to see the specialist, please email it before your appointment to office@westvicsurgical.com.au

Other informations

Clinic Booked or Interested in

How Did You Learn About Our Services?

Emergency Contact

Name

First Last

Relationship

Contact Number

Consent*

I give my consent to collect, use, and disclose my personal and medical information as outlined in the patient forms I have completed and submitted. I understand that this information will be used for the purpose of my medical treatment and may be shared with other healthcare providers as necessary.  I also understand that I have the right to revoke this consent at any time by contacting the practice.

WestVic Surgical provides high quality bariatric (weight-loss) surgery, endoscopy, and other surgical procedures to those in Ballarat, Bacchus Marsh, Bendigo, Melton, Caroline Springs, Williams Landing, Werribee and the Western Victorian region.

About us

Weight Loss Surgery

General Surgery

Patient Intake Form

Patient Intake Form(Bariatric) & Medical History

All Appointments

Phone: (03) 4331 9499

Fax: +61 3 86694325

E office@westvicsurgical.com.au

Our Location

Ballarat Clinic:
102A Drummond St Nth
Ballarat Central VIC 3350

Werribee Clinic:
Level 1/242 Hoppers Lane
Werribee VIC 3030

240 Hoppers Lane
Werribee 3030

And many other locations such as Bendigo, Caroline Springs, Melton, Williams Landing