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HOME
- Monthly Specials
ABOUT US
TREATMENTS
- SURGICAL
  - LIPO SCULPTING
  - EYELID RENU
- MEDICAL AESTHETICS
  - BOTOX
  - DERMAL FILLERS
  - SCULPTRA
  - THREAD LIFTS
  - IV INFUSIONS
  - PRP
  - PRF
AESTHETIC BEAUTY
SHOP
PRICE LIST

Weight Management Patient History Questionnaire 1/3

Profile, Weight, Social and Family History 1/3

Name

Date of Birth

Height

Weight

Blood Pressure

Heart Rate

Weight History - Closest estimates as applicable.

Lowest weight in the past 5 years?

Highest weight in the past 5 years?

Weight 1 year ago?

Other

Goal Weight

Do you use a home scale?

Yes

No

How often do you weigh yourself?

Have you had surgery?

Yes

No

If yes, which procedure and when?

Motivation for intervention:

Do you use Tobacco/ Vape

Yes

No

If yes, What?

How often/ much?

Do you drink alcohol?

Yes

No

If yes, What?

How often/ much?

Any Drug use?

Yes

No

If yes, What?

How often/ much?

History of Drug overdose?

If yes, When?

Is there obesity in your family?

Yes

No

If yes, please list:

Are there any medical illnesses in your immediate family?

Yes

No

Diabetes

Yes

No

Who/ Type:

Hypertension

Yes

No

Who/ Type:

Coronary Artery Disease

Yes

No

Who/ Type:

Cancer

Yes

No

Who/ Type:

Medullary Thyroid Carcinoma

Yes

No

Who/ Type:

Multiple Endocrine Neoplasia 2

Yes

No

Who/ Type:

Other

Yes

No

Please list all weight loss attempts, physician-supervised programes, as well as self-monitored diets.

Please include all weight loss drugs/ injections, teasand treatments tried.

Age you first started dieting:

Type of Diet (Ex: Keto. etc.)

List any physician-supervised and documented weight loss attempts.

Thank you for contacting us.
We will get back to you as soon as possible.

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HOME
- Monthly Specials
ABOUT US
TREATMENTS
- SURGICAL
  - LIPO SCULPTING
  - EYELID RENU
- MEDICAL AESTHETICS
  - BOTOX
  - DERMAL FILLERS
  - SCULPTRA
  - THREAD LIFTS
  - IV INFUSIONS
  - PRP
  - PRF
AESTHETIC BEAUTY
SHOP
PRICE LIST

Contact

Asteria Group

17 Midas Avenue, Olympus Boulevard Office Park, Heartsease Building, First Floor, Asteria House.

Reception: 012 998 4486

WhatsApp: 074 745 9104
Emergency After Hours Only (no bookings):

084 767 5954 / 084 547 1083

Email: admin@asteriasa.co.za

Clinic Hours

Mon - Fri: 8:00 am - 5:30 pm
Saturday: 8:00 am - 1:00 pm
Sunday: Closed

12/24/2025

9:00 am - 5:00 pm

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