Medilean Questionnaire Consent Forms Medilean Prescreen Name First Last Email PhoneMedical Aid Medical Aid Number Are you an existing patient Yes No If yes, who is your doctor? How yould you define your family body shape? Thin Average Obese Are you pregnant? Yes No Not Sure N/A If applicable – when was your last child born? MM slash DD slash YYYY What exercises are you currently doing and how much? How many liters of water do you drink per day?Are you smoking? Yes No If yes, how much per day? If you consume alcohol, how many units per week? What does your average breakfast include? What does your average lunch include? What does your average dinner include? What snacks do you eat on an average day? Consent(Required) I have read informed consent document for the procedure, understand it, accept these facts, and thereby authorize the doctor to give adequate treatment for weight loss.Read the informed consent document before ticking the above box.CAPTCHA