Weight Loss Questionnaire | Nairobi Bariatric Center

Step 1: Weight & Treatment Interest

Please provide your physical measurements and the procedures you are interested in.

Current Weight (kg) *

Height (cm) *

Highest Weight (kg) *

Waist Circumference (cm) (optional)

Calculated BMI

--Enter weight & height

BMI is computed automatically from your height and weight.

Ideal Weight (kg) (optional)

Kilograms to Lose (kg) *

Treatment(s) of Interest * (select all that apply)

Step 2: Medical History

Please answer accurately so our bariatric surgeons can evaluate clinical safety.

Do you frequently experience heartburn or acid reflux? *

YesNo

Have you been diagnosed with any mental health condition(s)? *

YesNo

Have you had any prior abdominal surgeries? *

YesNo

Are you currently taking any prescription medications or dietary supplements? *

YesNo

Does your daily routine or job require strenuous physical work or heavy lifting? *

YesNo

Do you have any drug, latex, or food allergies? *

YesNo

Do you smoke cigarettes or use nicotine products / vapes? *

YesNo

Alcohol Consumption *

NoYes, occasionally (e.g., on weekends or special occasions)Yes, regularly (e.g., weekly)Yes, heavily (e.g., more than 3-4 times a week)

Other Substances or Addictions *

When would you like to start your weight loss treatment? *

As soon as possibleIn 1-3 monthsIn 6 months or more

Step 3: Personal & Contact Information

Please provide your official contact details so our patient coordinators can follow up with your consultation booking.

First Name *

Middle Name (optional)

Last Name *

Gender *

FemaleMale

Age (years) (optional)

Nationality / Country of Residence *

Profession / Occupation *

Email Address *

Phone Number *

Preferred Payment Method *

CashPaybillBank Transfer

Privacy Commitment: Nairobi Bariatric Center respects patient confidentiality. Your medical information is encrypted and transmitted securely to our medical database in strict compliance with medical confidentiality standards.

Questionnaire Received!

Thank you for completing your consultation questionnaire. Your information has been securely received by our clinical team.

Status:Medical Review Pending

Next Step:Consultation Coordinator Contact

Expected Response:Within 24 Business Hours

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Weight Loss Procedures

Plastic Surgery

Weight Loss Consultation Questionnaire

Step 1: Weight & Treatment Interest

Step 2: Medical History

Step 3: Personal & Contact Information

Questionnaire Received!