IB Bari sx patient info and HQ Form

Title

First Name

Last Name

Address Line 1

Address Line 2

City

State

Postcode

Country

Date of Birth (DD/MM/YYYY)

Occupation

Phone/Mobile

Next of Kin

Relationship

Phone

Medicare No.

Reference No.

Expiry Date

Private Health Fund Name

Policy No.

Reference No.

Does this cover you for bariatric surgery?

Do you have a DVA card?

DVA No.

Colour of Card:

Are you considering using a superannuation to fund your surgery?

Do you smoke or vape?

If yes, how many per day?

Do you drink alcohol?

How many glasses a day/week?

Current Weight

Current Height

Do you have a specific weight-loss goal in mind?

Medical Conditions

Do you have or have ever had the following conditions?

Cancer

Heart Murmur/Heart Disease/Heart Attack/Palpitations/Angina

Pacemaker or other Heart implant

Epilepsy/fits/faints

Diabetes Diet/Tabs/Insulin Stomach

Problems with Gastric Ulcer /Ingestion/Reflux

Hepatitis

History of Blood Clots DVT/PE

Kidney Problems

Lung Disease

Allergies, please list any

Any complications with previous Surgery?

Anaesthetic?

Past Medical History

Any other significant conditions (please specify):

Are you currently under the care of any specialists for any of these conditions?

If yes, please specify:

Mental Medical History

Do you have a history of mental health conditions (e.g., depression, anxiety, eating disorders)?

Are you currently taking any medications for mental health conditions?

If yes, please list them:

Have you been hospitalized for mental health reasons?

If yes, please list them:

Medications & Supplements

Please list any medications you are currently taking, including dosages (e.g., hypertension meds, antidepressants, etc.):

Are you currently taking any vitamins or supplements?

If yes, please list them:

Support System

Do you have a support system at home (family, friends, etc.) who will be involved in your weight loss journey?

If yes, are they aware of your decision to pursue bariatric surgery?

Diet and Exercise

Please describe your current eating habits (e.g., number of meals/snacks per day, types of food, portion sizes):

Do you currently follow any specific diet plan (e.g., low carb, intermittent fasting)?

If yes, please specify:

How often do you engage in physical activity (e.g., walking, gym, sports)?

Emotional Eating Habits

Do you ever find that your emotions (such as stress, sadness, or boredom) influence your eating habits?

If yes or sometimes, could you describe how emotions typically impact your eating behaviours? (For example: do you eat more when stressed, or do you eat to cope with certain emotions?)

Additional Information

Is there anything else you would like us to know before your appointment?

Your Privacy, Our Concern – Consent to use your personal information

The information we have requested from you is very important for us to provide you with the best possible care and
outcome.

Dr Ian Baxter and The Sunshine Coast Medical Weight Loss Centre complies with the
Commonwealth Privacy Act and all other state and territory legislative requirements in relation to
the management of personal information. We collect information that is necessary for the provision
of your health care. Personal information obtained from you in your consultation may be used to
provide information to various health services involved in supporting your health care management
(e.g. pathology, radiology, hospitals or other specialists). We may contact you up to four times a year
by email to obtain statistical information for the Bariatric Surgery Register, patient support group
meetings and other health related information. Our website captures information for appointments,
and we may contact you by phone or email. Our Privacy and appointment cancellation policy is
available to view at reception or upon request. Your My Health Record will be accessed and your
information uploaded online to your records.
If the patient lacks capacity to consent, a guardian may sign on their behalf, with additional risk
considerations. Please contact us if this situation arises. By signing, you affirm that the provided
information is true and correct as of the date of completion. I have read and understood the Privacy
Policy and understand my rights and responsibilities

I hereby consent to my personal information being released as and when required.

Signature

Sign Here

Patient/Guardian/Power of Attorney

Patient/Guardian/Power of Attorney

Relationship

Guardian/Power of Attorney

Take the Next Step in Your Weight Loss Journey

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