Weight Loss Consultation – Patient Questionnaire

Welcome 👋

📝 This questionnaire helps your doctor understand your health, lifestyle, and medical background so that your consultation is safe, accurate, and tailored to your needs. Please answer honestly and to the best of your ability.

Please fill it out as early as possible to ensure the doctor as time to prepare everything you need.

Thank you for your cooperation!

1. Personal Information 🧑‍💻

2. Body Measurements 📏⚖️

Kilograms
Centimetres

3. Current Weight Loss Assistance 💊

4. Lifestyle Information 🏃‍♀️🥗💤

5. Medical Conditions 🧬

6. Medical History 📜

7. Continuity of Care 🤝

8. Important Acknowledgements

In relation to the General Data Protection Regulation