Medical Questionnaire

A medical questionnaire will be sent upon request, see Contact Us. Dr. Jean-Pierre Anfroy is committed to respecting the confidentiality of this information.


Name:

First Name:

Male / Female:

Address:

Country:

Phone:

Mobile phone:

Email address:

Date of birth:                

Profession:

Married:

Children:

Weight (kg:      ) (st:      )

Height:

2. Family history of obesity and heredity

Father, mother: Obesity, Diabetes, Hypertension:

3. Any other associated diseases

Diabetes:

High blood pressure:

Varicose veins:

Gynaecological:

Joint pain:

Thyroid:

Somnolence / snoring / sleep apnea:

4. Results of recent blood tests available: Yes / No:

5. Medication:

6. Former operations:

7. Other remarks:

Date:

© Dr. Jean-Pierre Anfroy | Last update 15/03/16