Circle of Care - Institute of Weight Control
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Patient proforma

Fields marked (*) are compulsory

 

  Title 
     
  Surname:*   Other Names:
     
  Date of Birth: Age:
     
  Home Address 
     
  Post Code:    
 
     
  Postal Address   
 
     
  Phone Number: Home* Work  
 
     
  Mobile E-Mail*  
     
  Occupation Name of Next of Kin  
     
  Medicare Number / / /  
     
  Exp: / / Ref:  
     
  Name of Private Health Fund Membership Number  
     
  Are you an Aged Pensioner? If yes Pension Number  
     
  Do you have a Veterans’ Affairs Card? If yes Pension Number  
     
  Do you have a Veterans’ Affairs Card? If so Veterans’ Number
     
Name of Referring Doctor
Name of your GP (if not referring Doctor)
Address of your GP (if not referring Doctor)
How did you find out about Circle of Care?
     
Do you consent for your information to be shared with the
National Bariatric Surgery Registry of which our clinic contributes to?
  Yes No
     
WEIGHT LOSS HISTORY:
PAST ATTEMPTS :
 
Weight Watchers  

Jenny Craig/Nutrisystem/Gloria Marshall etc

 
Hypnotherapy  
Fad diets  
Appetite suppressants  
Any other drug treatment  
Have you had previous weight loss surgery?      
     
PERSONAL MEDICAL HISTORY
Have you ever suffered with any of the following health problems:
Diabetes:   Yes No
Asthma:   Yes No
Respiratory/Breathing problems:   Yes No
Arthritis or joint pain:   Yes No
Back pain:   Yes No
Kidney or urinary disorder:   Yes No
Neurological:   Yes No
Psychological/nervous disorder:   Yes No
Gallstones:   Yes No
Reflux or heartburn:   Yes No
Gastric or duodenal ulcer:   Yes No
Hepatitis or liver disease:   Yes No
High blood pressure:   Yes No
Heart disease:   Yes No
High cholesterol:   Yes No
Anaemia or bleeding disorder:   Yes No
Thrombosis or clotting disorder:   Yes No
Varicose veins or leg swelling:   Yes No
Eczema or skin condition:   Yes No
Hayfever or Rhinitis:   Yes No
Thyroid Disease:   Yes No
 
Ladies:
Irregular Periods:   Yes No
Excessively heavy periods:   Yes No
Difficulty conceiving:   Yes No
Excess body hair or acne:   Yes No
Polycystic ovaries:   Yes No
Please give details of any major illnesses/problems:      
     
SURGICAL HISTORY :
Please give details of any past operations & any hospital stays in the last 6 months:  
     
Any problems with anesthesia?   Yes No
If yes please describe:     
     
ALLERGIES
(including foods, medications, dressings
  Yes No
If yes, please give details:     
MEDICATIONS :
Please list all medications and their doses including dietary, multivitamins (B12, folate)etc:  

Diabetes:
Juvenile Onset: Yes No Year Diagnosed:

Adult Onset: Yes No Year Diagnosed:

Whilst pregnant: Yes No Year Diagnosed:

   
     
Current form of Control:
     
Diet Control Only: Yes No As of (year):

Medication (tablets): Yes No As of (year):

Details:
Insulin: Yes No As of (year):

Type and No of injections per day
HbA1C
Current blood sugar level:
     
Sleep History:
     
Do you have Obstructive Sleep Apnoea?: Yes No
Do you use C-Pap?: Yes No Pressure: cmH20

     
Please answer each question, best indicates your answer:
     
1.How often do you snore?   Never Always
2.Do you wake during the night with a choking feeling?   Never Always
3.How often would you sleep more than 8 hours in total in a 24 hour period?   Never Always
4.How often do you wake up more than once during the night?   Never Always
5.Do you have a headache when you wake up in the morning?   Never Always
6.Have you noticed a reduction in your libido or sex drive?   Never Always
7.Do you feel sleepy during the day?   Never Always
8.Has anyone noticed that you momentarily stop breathing during your sleep?   Never Always
9.Do you fall asleep while reading?   Never Always
10.Do you wake up in the morning feeling confused?   Never Always
11.How often do you have a nap during the day?   Never Always
12.Do you feel sleepy in the evenings?   Never Always
13.Have you or anyone else noticed a change in your personality recently?   Never Always
14.How often do you doze off or fall asleep while driving?   Never Always
     
How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently, try to work out how they would have affected you.
  Never doze Slight chance of dozing Moderate chance of dozing High chance of dozing
Sitting and reading
Watching TV
Sitting, inactive in a public place
(e.g. a theatre or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in the traffic
     
If your sleep is a major problem to you or your partner, would you be prepared to have a sleep study performed now and after you lose weight?   Yes No
     
     
Asthma:
Have you ever had asthma? (tick one of the following) 
Never  
Current  
In the past  
Don’t know  
     
Have you ever had to spend a night in hospital because of asthma / breathing problems?   Yes No
If yes was it in the last 12 months   Yes No
In the last 12 months, have you taken a course or prednisolone because of asthma or breathing problems   Yes No Details :
In the last 12 months, have you missed work or school because of asthma or breathing problems?   Yes No Details :
     
Gastro oesophageal Reflux / Indigestion
     
Do you have a history of heartburn or indigestion?   Yes No Details :
     
If yes, how often do you have reflux during the day?  
Many times a day
Everyday
Most days
Most weeks
Occasionally
     
Do you suffer heart burn / indigestion during the night? If so how often  
Many times a night
Everynight
Most nights
Most weeks
Occasionally
     
     
What aggrevates or causes your reflux?  
     
Do you have difficulty swallowing?   Yes No Details:
Does food ever get stuck?   Yes No Details:
Does food or fluid reflux into the mouth?   Yes No Details:
Do you vomit with reflux?   Yes No Details:
Do you suffer from recurrent sore throats?   Yes No Details:
Do you suffer from a hoarse voice?   Yes No Details:
Do you suffer from a regular cough at night?   Yes No Details:
     
Please list any treatments you may use for reflux / heartburn or indigestion  
     
BECK DEPRESSION QUESTIONNAIRE
     
1 I do not feel sad
  I feel sad
  I am sad all the time and I can’t snap out of it
  I am so sad or unhappy that I can’t stand it
     
2 I don’t have any thoughts of killing myself
  I have thoughts of killing myself but I would not carry them out
  I would like to kill myself
  I would kill myself if I had the chance
     
3 I am not particularly discouraged about the future
  I feel discouraged about the future
  I feel I have nothing to look forward to
  I feel the future is hopeless and that things cannot improve
     
4 I do not feel like a failure
  I feel I have failed more than the average person
  As I look back on my life, all I can see is a lot of failures
  I feel I am a complete failure as a person
     
5 I get as much satisfaction out of things as I used to
  I don’t enjoy things the way I used to
  I don’t get real satisfaction out of anything any more
  I am dissatisfied or bored with everything
     
6 I don’t feel particularly guilty
  I feel guilty a good part of the time
  I feel quite guilty most of the time
  I feel guilty all of the time
     
7 I don’t feel I am being punished
  I feel I may be punished
  I expect to be punished
  I feel I am being punished
     
8 I don’t feel disappointed in myself
  I am disappointed in myself
  I am disgusted with myself
  I hate myself
     
9 I don’t feel I am any worse than anybody else
  I am critical of myself for my weaknesses or mistakes
  I blame myself all the time for my faults
  I blame myself for everything bad that happens
     
10 I am no more irritated now than I ever am
  I get annoyed or irritated more easily than I used to
  I feel irritated all the time now
  I don’t get irritated at all by the things that used to irritate me
     
11 I have not lost interest in other people
  I am less interested in other people than I used to be
  I have lost most of my interest in other people
  I have lost all of my interest in other people
     
12 I make decisions about as well as I ever could
  I put off making decisions more than I used to
  I have greater difficulty in making decisions than before
  I can’t make decisions at all anymore
     
13 I don’t feel I look any worse than I used to
  I am worried that I am looking old or unattractive
  I feel that there are permanent changes in my appearance that make me look unattractive
  I believe that I look ugly
     
14 I can work about as well as before
  It takes an extra effort to get started at doing something
  I have to push myself very hard to do anything
  I can’t do any work at all
     
15 I can sleep as well as usual
  I don’t sleep as well as I used to
  I wake up 1-2 hours earlier than usual and find it hard to get back to sleep
  I wake up several hours earlier than I used to and I cannot go back to sleep
     
16 I don’t get more tired than usual
  I get tired more easily than I used to
  I get tired from doing almost anything
  I am too tired to do anything
     
17 My appetite is no worse than usual
  My appetite is not as good as it used to be
  My appetite is much worse now
  I have no appetite at all any more
     
18 I don’t cry any more than usual
  I cry more now than I used to
  I cry all the time now
  I used to be able to cry, but now I can’t cry even though I want to
     
19 I am no more worried about my health than usual
  I am worried about physical problems such as aches and pains; or upset stomach; or constipation
  I am very worried about physical problems and it is hard to think of much else
  I am so worried about my physical problems that I cannot think about anything else
     
20 I haven’t lost much weight, if any, lately
  I have lost more than 2 kgs
  I have lost more than 5 kgs
  I have lost more than 10kgs
     
21 I have not noticed any recent change in my interest in sex
  I am less interested in sex than I used to be
  I am much less interested in sex now
  I have lost interest in sex completely
     
     
ALCOHOL:
     
Do you drink alcohol?   Never Rarely Regularly
How many standard glasses do you drink per day?  
How many days do you drink per week?  
Do you drink?   Beer Wine Spirits
     
SMOKING:
     
Do you smoke?   Yes No Never

If yes: how many per day?:  

Have you smoked in the past?   Yes No Never

If yes: how many per day?:  

For how many years :  

When did you stop smoking?:  

     
ACTIVITY LEVEL
What exercise do you do on a regular basis?
     
     
FAMILY MEDICAL HISTORY
Do you have a family history of any of the following and if so, please indicate:
     
         
  Obesity    
  Diabetes    
  Heart Disease    
  Hypertension    
  Gout    
  Gallstones    
  Snoring / sleep apnoea    
  Asthma    
  Allergies    
  Hayfever    
  Dermatitis / Eczema    
  High Cholesterol    
  Osteoporosis    
  Hip fractures    
     
RAND 36-ITEM HEALTH SURVEY 1.0
     
INSTRUCTION: Please answer all questions by ticking a number for each question.
     
1 In general, would you say your health is:    
  (tick one number on each line) *  
  Excellent
  Very good
  Good
  Fair
  Poor
     
2 Compared to one year ago, how would you rate your health in general now?    
  (tick one number on each line) *  
  Much better
  Somewhat better
  The same
  Somewhat worse
  Much worse
     
The following questions are about activities you might do during a typical day. Does your health now limit you in these following activities, if so how much?
(tick one number on each line) *
     
    Yes limited a lot Yes limited a litte No, not limited at all
3 Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports.
4 Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf.
5 Lifting or carrying groceries
6 Climbing several flights of stairs
7 Climbing one flight of stairs
8 Bending, kneeling or stooping
9 Walking more than one kilometre
10 Walking half a kilometre
11 Walking 100 metres
12 Bathing or dressing yourself
         
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your PHYSICAL health?
(tick one number on each line) *
    Yes No
13 Cut down the amount of time you spent on work or other activities.
14 Accomplished less than you would like.
15 Were limited in the kind of work or other activities.
16 Had difficulty performing work or other activities, (for example it took extra effort)
     
During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any EMOTIONAL problems (such as feeling depressed or anxious)?
(tick one number on each line) *
       
    Yes No
17 Cut down the amount of time you spent on work or other activities. 
18 Accomplished less than you like. 
19 Didn’t do work or other activities as carefully as usual. 
     
     
20 During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbours or group.
Not at all
Slightly
Moderately
Quite a bit
Extremely
21 How much bodily pain have you had during the past 4 weeks
None
Very mild
Mild
Moderate
Severe
Very severe
22 During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)
Not at all
A little
Moderately
Quite a bit
Extremely
     
The following questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.
     
How much of the time during the last 4 weeks . . .
 
    All the time Most of the time A good bit of time Some of the time A little of the time None of the time
23 Did you feel full of life
24 Have you been a very nervous person
25 Have you felt so down in the dumps that nothing could cheer you up.
26 Have you felt calm and peaceful
27 Did you have alot of energy?
28 Have you felt down.
29 Did you feel worn out?
30 Have you been a happy person
31 Did you feel tired.
32

During the past 4 weeks how much of the time has your physical health or emotional
problems interfered with your social activities (like visiting friends, relatives, etc)?

  (tick one number on each line) * All of the time
    Most of the time
    Some of the time
    A little of the time
    None of the time
How true or false is each of the following statements for you?
  (tick one number on each line) * Definitely True Mostly True Don't know Mostly False Definitely False
33 I seem to get sick a little easier than other people
34 I am as healthy as anybody I know
35 I expect my health to get worse
36 My health is excellent
     
MULTI-DIMENSIONAL BODY SELF RELATIONS QUESTIONNAIRE
The following section contains a series of statements about how people might think, feel, or behave.
You are asked to indicate the extent to which each statement pertains to you personally. Read each statement carefully. Tick the most appropriate number on the scale below for each question.
     
  1 Definitely disagree  
  2 Mostly disagree  
  3 Neither agree nor disagree  
  4 Mostly agree  
  5 Definitely agree  
       
1. 1 2 3 4 5 Before going out in public, I always notice how I look
2. 1 2 3 4 5 I am careful to buy clothes that will make me look my best
3. 1 2 3 4 5 My body is sexually appealing.
4. 1 2 3 4 5 I like my looks just the way they are
5. 1 2 3 4 5 I check my appearance in a mirror whenever I can.
6. 1 2 3 4 5 Before going out, I usually spend a lot of time getting ready.
7. 1 2 3 4 5 Most people would consider me good-looking
8. 1 2 3 4 5 It is important that I always look good
9. 1 2 3 4 5 I use very few grooming products.
10. 1 2 3 4 5 I like the way I look without my clothes
11. 1 2 3 4 5 I am self-conscious if my grooming isn’t right
12. 1 2 3 4 5 I usually wear whatever is handy without caring how it looks.
13. 1 2 3 4 5 I like the way my clothes fit me.
14. 1 2 3 4 5 I don’t care what people think about my appearance.
15. 1 2 3 4 5 I take special care with my hair grooming.
16. 1 2 3 4 5 I am physically unattractive
17. 1 2 3 4 5 I never think about my appearance
18. 1 2 3 4 5 I am always trying to improve my physical appearance.
     
1. Usually I Feel....    
Very Badly About Myself 1 2 3 4 5 6 7 8 9 10 Very Good About Myself
     
2. I Enjoy Physical Activities....    
Not at all 1 2 3 4 5 6 7 8 9 10 Verymuch
     
3. I have Satisfactory Social Contacts.....    
None 1 2 3 4 5 6 7 8 9 10 Verymuch
     
4. I Am Able to Work........    
Not At all 1 2 3 4 5 6 7 8 9 10 Verymuch
     
5. The Pleasure I get Out Of Sex Is...    
Not At all 1 2 3 4 5 6 7 8 9 10 Verymuch
     
6. The Way I Approach Food Is...    
I Live to Eat 1 2 3 4 5 6 7 8 9 10 I Eat to Live
     
BMI Calculator :
     
Weight (Kg)
Height (Cm)
BMI Calculator
The BMI is
     
     

BMI Ranges: What they mean

18.5 Underweight
18.5 - 25 Normal
25 - 30 Overweight
Above 30 Obese
Above 35 Severely obese
Above 40 Morbidly obese
Above 50 Super Obese
     
     
 

This document begins the process of collection of your information for the following purposes:

  • Health information to assist in the management of your care
  • Administration of this medical practice
  • Billing, including compliance with Medicare and Health Insurance Commission requirements
  • Disclosure to others involved in your health care, including doctors and specialists outside this practice who may become involved in treating you. This may occur through referral to other doctors, or for medical tests and in the reports or results returned to us following referrals. If these providers share your information with us, this will also form part of your file.
  • Disclosure for research and quality assurance activities to improve individual and community health care and practice management.
  • We may share the collected information with other health providers that have treated you, or may treat you in the future, e.g. your G.P..

I have read the above information and understand why collecting this information about me may be necessary. I am also aware that this practice has a privacy policy on handling patient information.

I understand that if my information is to be used for any other purpose other than set about above, my further consent will be obtained. I acknowledge that I have read this form before signing it and that a member of the staff of this practice has at my request clarified any aspects of it that I did not understand at first.

 
     
     
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