BGOS Gastric Balloon Program Registration Form and Questionnaire

This form will be used to determine whether you are suitable for a Gastric Balloon Program. It may not be possible to determine suitability in all cases from this form alone and ultimately our doctors have the final say on whether someone is suitable or not.

PLEASE NOTE THAT WE ARE A BRISBANE AND REDCLIFFE BASED PRACTICE. IF YOU ARE LOCATED IN A DIFFERENT STATE, WE RECOMMEND TO FIND A PROVIDER CLOSER TO YOUR LOCATION.

If you are suitable, we will be able to offer you a one-on-one consultation with one of our qualified doctors to confirm your suitability and answer any questions you may have.

From that point, if you wish to proceed, you will be able to complete paperwork and book a balloon placement date.

BY COMPLETING THIS FORM, THERE IS NO OBLIGATION TO PROCEED WITH ANY TREATMENT WITH BRISBANE GENERAL & OBESITY SURGERY.

Information on our Privacy Policy can be viewed on our website bgos-allurion.com.au

Full Name *

Date of Birth *

Mobile Number *

Email Address *

Occupation? *

Address *

Street address *Street address line 2

City *

State *

Postcode *

Medicare Number *

Expiry Date *

Private Health Insurance?

YesNo

Health Fund

Membership Number

Policy Level of Cover

Next of kin *

Contact number *

Name of GP *

Practice Details for GP *We require your GP's details to be able to write correspondence and documentation for Medicolegal reasons

Why are you interested in a Gastric Balloon Program? *

How did you hear about us? *

GoogleInstagramFriend/Family

Current Weight (kg) *

Current Height (in METRES e.g. 1.72m) *

BMI Calculator

Tell us about how you have struggled with your weight? *

Do you smoke cigarettes or tobacco? *

YesNoVape

How many alcoholic standard drinks do you consume in a week? *

Do you do any regular exercise or physical activity currently? *

What have you tried in the past to manage your weight and improve your health and lifestyle? *

What are you currently doing to manage your weight and improve your health and lifestyle? *

If you move forward to a Gastric Balloon, you are going to require a period of VLCD (Very Low Calorie Diet) shakes before and after your balloon is placed. Do you have any allergies or sensitivities to any products, for example, lactose, gluten? *

If you have tried VLCD (Very Low Calorie Diet) shake products before, what has been your experience? *

Other Medical Conditions *

Do you take any medications? Please list all including dosage *

Do you have any allergies? Please list all including type of reaction. *

Have you had any previous abdominal surgery? *

Do you have any questions?

Which program are you interested in?

How will you be funding the program? (Self-funding, Superannuation etc)

I confirm that the information that I have provided is true and correct to the best of my ability. I accept responsibility that an accurate assessment or treatment recommendation is not possible if accurate information has not been provided to Brisbane General & Obesity Surgery. *

Name *

Signature *

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Date Signed *

Please contact us once you have completed this form, to discuss whether a Gastric Balloon is potentially suitable for you.

Phone: (07) 3153 6633 Email: admin@brisbanegosurgery.com.au

Dr Aaron Lim Provider Number: 475765HT

Dr Jason Wong Provider Number: 511529DH