Become a Patient | Prof Tess

First name

Last name

Title

Email

Phone

Medical Aid Provider

Medical Aid Plan

Medical Aid Number

Are you currently upgrading your medical aid plan?

Height (cm)

Weight (kg)

ID Number/Passport Number

Which treatment pathway are you intersted in?

Bariatric Surgery

Weight Loss Medication

Unsure

Biological Sex

Are you currently pregnant?

Yes

No

Unsure

Not Applicable

Have you had previous obesity surgery? I.e gastric bypass, balloon, band, small bowl bypass etc. ? Kindly provide the details and date, if applicable.

Have you seen Prof Tess before?

Do you have any allergies? If so, please provide the details thereof.

Do you routinely use anti-inflammatory medication?

If applicable, kindly list all current medications that you are taking.

Have you been diagnosed with any of the following by a medical doctor? (Select all applicable)

Have you been through alcohol addiction rehabilitation? If so, kindly provide brief details.

Have you been through any other addiction rehabilitation? If so, kindly provide brief details.

Are you an active smoker or vaper? If so, what is your current intake?

Do you currently belong to a CDE program? (Centre for Diabetes and Endocrinology Program).

Kindly list your last known blood pressure, along with the approximate date thereof. Alternatively, enter "unknown" or "unsure."

Kindly list your last known fasted blood glucose level, along with the approximate date thereof. Alternatively, enter "unknown" or "unsure."

Kindly list your last known cholesterol, along with the approximate date thereof. Alternatively, enter "unknown" or "unsure."

Do you have sleep apnea?

Are you currently using a CPAP machine for sleep apnea?

Kindly provide a history of previous surgery and surgical admissions to hospital.

Kindly provide a history of previous internal medical and other relevant admissions to hospital.

Have you been previously diagnosed with infectuous diseases such as Covid, Malaria, Bilharzia etc. ?

Have you previously undergone open pelvic or abdominal surgery? Kindly provide brief details.

Kindly list any medical or other relevant information that you wish to bring to our attention.