To assist us with your consultation please complete the following online form prior to your appointment.
Alternatively you can download a PDF of the form to complete manually here. Health Questionnaire
Title
First Name *
Surname *
E-Mail *
Date of Birth *
Do you Smoke? * YesNo
Do you Drink Alcohol? * YesNo
Do you have or have you ever had, the following conditions, please select “Yes” to any relevant condition.
Diabetes YesNo
Diabetes controlled by: NADietTabletsInsulin
Heart Attack / Palpitations / Angina Yes
Heart Murmur / Heart Disease Yes
Pacemaker or other HEART implants Yes
Lung disease Yes
Hepatitis Yes
Epilepsy / fits / faints Yes
Cancer Yes
Kidney problems Yes
Blood disorder / bleeding Yes
Stomach problems / Gastric ulcer / Indigestion / Reflux Yes
Operations - Date (if known)
Any complications with previous surgery? YesNo
Any complications with previous Anaesthetic? YesNo
Current Medications
Medical Allergies
Height (cm) *
Weight (kg) *
Your Privacy, Our Concern – Consent to use your personal information
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).
I have read and understood the Privacy Policy and understand my rights and responsibilities.
I certify that the information given above is true and correct to the best of my knowledge and ability and I hereby consent to my personal information being released as and when required *
