Surname: _________________________________ Given Names:___________________________ Address:_________________________________________________________________________ _________________________________________________Postcode:_______________________ Telephone No: (Home) ________________________ (Bus): _______________________________
Mobile No:____________________________ Date Of Birth ________________ Age ___________
Email:___________________________________________________________________________
Health Insurance Fund:_____________________________ Membership No: __________________
Medicare Number: _____________________ No. on Card:__________________ Exp: __________
Veteran Affairs: _______________________________________ Exp: ________________________ Pension Card: ________________________________________ Exp: ________________________ NEXT OF KIN (mandatory)
Name:__________________________________________ Relationship:______________________ Telephone No:________________________________ REFERRAL DETAILS It is very important that your GP and Specialist doctors are informed of your weight loss especially if
you are taking medication for any related problems. Please infom the clinic of all yoir doctors.
GP Details: :_____________________________________________________________________ Address:____________________________________________Phone:________________________ Specialist Doctors: ________________________________________________________________ ________________________________________________________________________________ HOW DID YOU HEAR ABOUT EASTERN OBESITY CLINIC?
Newspaper Magazine/Courier Website General Practitioner Family/Friend __________________________ Other _____________________________
Office Use only WEIGHT HISTORY What is your current weight? ___________ maximum weight? ________ Cause Of Xs Weight/Food weakness (circle):
Alcohol/Liquids Pregnancy-Related Other
Causes____________________________________________________________________ What’s Been Tried?
Other__________________________ How seriously have you tried these measures? (circle); Most amount of weight loss ___________ How long maintained __________ (months) Why do you feel it didn’t work?: _______________________________________________ Exercise At Present Time:
__________________________________________________________________________ How long have you been thinking about weight loss surgery / balloon? ________________ _______________________________________________________ What research have you done? (circle); info night, know someone who has had the procedure, internet, brochure, consult with obesity surgery staff, other __________________________ Do you feel you have a reasonable knowledge of the following procedures (circle);
Gastric balloon, Laparoscopic Gastric Band, or Laparoscopic Sleeve (tube) Gastrectomy
Do you have support from (please circle); family, partner, local doctor, specilialist, friend, other
(list) _________________________________________________________________
What is your motivation (circle); energy level, short or long term health, appearance,
self esteem, fear of premature death, comorbid disease control, comorbid disease prevention, social
isolation, mobility, other (list) _________________________________________________________
PERSONAL MEDICAL HISTORY
Are you planning to get pregnant soon? Details: Have you ever suffered with any of the following health problems:
Arthritis/ joint pain / joint surgery Yes
Please list all allergies,including drugs, dressing or food. ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Please give details of any major illnesses/problems: _____________________________________
Please list all past operations ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ Do you take any regular medications?(please list strength and frequency) ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________
Please list all vitamins and supplements you take ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ______________________________________________________________________ ALCOHOL: Do you drink alcohol? Never Rarely Regularly
How many standard glasses do you drink per day/week? ______________
SMOKING: Do you smoke? Yes No Never If yes: how many per day? ___________________ Have you smoked in the past? Yes No If so, how many per day? ____________________ FAMILY MEDICAL HISTORY
Do you have a family history of any of the following and if so, please indicate:
OTHER RELATIVES (cousins, aunts, grandparents etc)
Krankenhaushygiene Empfehlungen METHICILLIN-RESISTENTE S. aureus MRSA Leitfaden im Umgang LEITFADEN ZUM UMGANG MIT METHICILLIN-RESISTENTEN S. AUREUS (MRSA) Grundsätzlich gilt: • MRSA sind per se nicht virulenter als andere Staphylokokkus aureus • Hauptreservoir ist der Nasen-Rachen Raum• MRSA werden v.a. über die Hände übertragen• Händedesinfektion schützt
A mother, who had suffered gestational diabetes in her pregnancy, (and still has polyuria and polydypsia), saw me with her baby of seven weeks, for breast pain. She describes it as a shooting burning pain and reports that her nipples (which are rosy red) blanch during the episodes of pain. Her pregnancy was further complicated by a ruptured appendix at 33 weeks for which she underwent emerge