Obesity Questionaire








Male Female











How much weight would you like to lose?




Yes No
Weight related illness:-

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Medical History:-
Please mention details about your medical history, including, but not limited to –
  1. Details of any surgery that you have undergone in the past
  2. If you ever had any problem with anaesthesia, please elaborate
  3. If you suffer from any chronic ailment, please furnish details
  4. If you are on any long term medication, Please list the name of medicines with their dosage
  5. If you are allergic to any medicine or drug, please mention details

Social History:-

Yes No


Yes No


Yes No


Yes No

Only For Female patients:-




Yes No


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