Unintentional Weight Loss - {{first name}} {{surname}}

General Information

First Name

Surname

Date of Birth

Email Address

Home Phone

Mobile Phone

Home Address

How did you find out about us?

Emergency Contact Information

Emergency contact

Phone

Emergency contact’s relationship to you

Work Information

Current work status

EmployedRetiredNot workingLight Duty

Occupation

Health Information

Unintentional weight loss

Intentional weight loss through diet or exercise

Rapid weight loss (more than 5% body weight in 6 months)

Gradual weight loss

Other

Associated symptoms

Loss of appetite

Fatigue or weakness

Nausea or vomiting

Diarrhoea or frequent bowel motions

Abdominal pain

Fever or night sweats

Shortness of breath

Persistent cough

Difficulty swallowing

Changes in mood or mental health (e.g. depressed, anxious)

Other

Eating and Nutrition

Reduced food intake

Difficulty chewing or swallowing

Changes in dietary habits

Food intolerances or allergies

History of eating disorder (e.g. anorexia, bulimia)

Other

Medical Background

List your medical conditions (e.g. High Blood Pressure, Asthma, Diabetes etc.)

Please list any medications you are currently taking.

Medications (Include Name, Dose and Frequency)

Please list any allergies.

Allergy

Please list any surgeries.

Surgery

Do you smoke?

YesNoI used to smoke

Do you use recreational drugs?

NoI have previously usedI currently use

Please upload any additional information.

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Consent

I confirm that the above information I have provided is true, complete and accurate. I agree to be contacted by a health professional via telehealth. *

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