1. Name Surname

2. Weight (kg)KgLbs

Height (cm)CmInch

3. Sex

Female Male

4. Age

5. Telephone No.

5. Please check your diseases

Diabetes Typ 1

Diabetes Typ 2

Insulin Resistance

Heart Disease

Hypertension

Lumbar Disk Disease

Cancer

6. Please check your other diseases

Reflux

Gastritis

Joint Disorders

High Colesterol

Dislipidemi (High Cholesterol)

Menstrual disorders

Psychological Disorders

Sexual Problems

Asthma

7. Do you have any psychiatric diagnosis related to drug and alcohol addiction?

Yes No

8. Do you have any psychiatric diagnosis related to an eating disorder?

Yes No

9. Please check chronic or hereditary diseases that your family has (father, mother, brother or sister etc.)

Diabetes Type 1

Diabetes Type 2

Insulin Resistance

Blood Pressure

Heart Disease

Cancer

10. If you take any medicine regularly, please write them below

11. Do you smoke? (Please consider last 3 months)

Yes, I smoke 1/2 package a day. Yes, I smoke one package a day Yes, more than a package a day No I don’t smoke

12. Have you ever tried to lose weight before?

YesNo

13. How was your weight during your adolescence? (The ages between 10 and 19 years old)

I was overweight I was overweight I was normal weight. I was thin.

14. If you want to solve your obesity problem via an operation, what your family and your close circle of friends’ reaction would be?

They will support me Even if they don't support, they respect my decision They don't support this decision

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