ENQUIRY

Please complete the following form and submit it to Dr Brombacher. Please note that this information goes directly to Dr Brombacher and is treated in the strictest confidence.

Patient Details
First Name requiredA value is required.
Last Name: Surname required.
Birth Date: A value is required.
Gender:

Please make a selection.

 

Contact Details:
Work number:
Home number:

Cell number:

Email:
Postal address:

 

Patient History:
Did you suffer from childhood obesity?


Have you gained more than 10kg since you were 18 years old?


If you answered "Yes" to the above question, briefly give details:
Did you gain more than 5% of your total body mass during pregnancy?


If you answered "Yes" to the above question, how much weight did you gain?
Is there a family history of Diabetes?


Do you suffer from Diabetes?


If you answered "Yes" to the above question, what drugs do you take?
Have you lost weight in the past?
If you answered "Yes" to the above question, briefly give a history:
Give a brief overview of your exercise regime:

 

Clinical Details:
Height (cm):
Weight (kg):
BMI (Calculate below):
Waist (cm):
Blood pressure: (if you know it)
Pulse per minute:

 

Habitual Consumption:
Are you a Smoker?


What do you smoke?





How many per day?
If you answered that you were not a Smoker, have you ever smoked before?


If you answered "Yes" to the above question, when did you give up?
Do you drink Alcohol?


If "Yes", what type:





How many glasses per day (on average)?
Other relevant substance abuse?

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