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5th Avenue Office Suites, 7th floor, Room 16, Ngong Road

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5th Avenue Office Suites, 7th floor, Room 16, Ngong Road

(254) 703 550 550
hello@nairobibariatric.co.ke

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Our Services
About Us
BMI Calculator
Testimonials
Our Community
- Blog
- Patient Support Group
Contact Us

5th Avenue Office Suites, 7th floor, Room 16, Ngong Road

Facebook Instagram Linkedin Youtube

5th Avenue Office Suites, 7th floor, Room 16, Ngong Road

(254) 703 550 550
hello@nairobibariatric.co.ke

Instagram Tiktok Youtube Facebook

Our Services
About Us
BMI Calculator
Testimonials
Our Community
- Blog
- Patient Support Group
Contact Us

Questionnaire

Please fill the form below

let's get to know you better

NBC Questionnaire

Notify

Your Current Weight in (Kgs)

Your Height (cm)

Your Highest Weight (Kgs)

Your Waist circumference (cm)

Your Current B.M.I

How many kilograms would you like to lose?

Please choose treatment of interest

Gastric Balloon

Allurion Balloon

Gastric Bypass

Gastric Sleeve

Ozempic for Weight Loss

Surgical aftercare

Psychotherapy

Individual therapy

Bowel Irrigation

Mini Bypass

Do you suffer/have you suffered from any obesity related conditions?

Yes

No

Please specify conditions

Other

Joint Pain

High Blood Pressure

Diabetes

High Cholesterol

Allergies

Varicose Vein

Back pain

Swollen Legs

Obstructive Sleep Apnea (snoring while sleeping)

Infertility

Deep Vein Thrombosis

Unexpected Tiredness

Reduced Sexual Activity

Cancer

Does any member of your family suffer from any of the below?

Yes

No

Please specify conditions

Other

Obesity

Joint Pain

High Blood Pressure

Diabetes

High Cholesterol

Allergies

Varicose Vein

Back pain

Swollen Legs

Obstructive Sleep Apnea (snoring while sleeping)

Infertility

Deep Vein Thrombosis

Unexpected Tiredness

Reduced Sexual Activity

Cancer

Do you have any digestive system problem?

Yes

No

Please specify conditions

Other

Indigestion

Constipation

Loose Stool

Heartburn

Bloated Stomach

Abdominal pain

Are you suffering from heartburn (acid reflux)?

Yes

No

Do you have any mental health conditions?

Yes

No

Please specify mental condition

Have you had any abdominal surgery before?

Yes

No

Please specify surgery

Are you on any medication/ supplements?

Yes

No

Please specify medication/ supplements

Does your job require any physical work or lifting heavy objects?

Yes

No

Have you tried to lose weight in the past?

Yes

No

Which methods did you use?

Other

Dietetics

Exercises

Meal plans

Slimming Medication

Food Supplements

Psychotherapy

Bariatric Surgery

Gastric Balloon

Detox (Bowel Irrigation)

Psychotherapy

Do you have any allergies?

Yes

No

Please specify allergy

Do you smoke

Yes

No

Do you consume alcohol?

Yes, occasionally (e.g., on weekends or special occasions)

Yes, regularly (e.g., weekly)

Yes, heavily (e.g., more than 3-4 times a week)

No

Do you use any other substances or have any addictions?

When would you like to start your weight loss treatment?

First Name

Last Name

Gender

Male

Female

Your Age

Nationality

Profession

Email

Phone/Mobile

Get in touch

Call : +254 703 550 550

hello@nairobibariatric.co.ke
Mon-Fri 8am - 5pm | Saturday 9am-3pm

Book appointment

Safe & Lasting Weight Loss Solutions

We are the pioneer Weight Loss Clinic with over two decades’ experience in the treatment of obesity and its related illnesses in East Africa.

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Address

5th Avenue Office Suites, 7th floor, Room 16, Ngong Road
hello@nairobibariatric.co.ke

Our Services

Gastric Balloon

Psychotherapy of eating habits

Bowel Irrigation

Surgical aftercare packages

Obesity related diseases

Quick Links

B.M.I Calculator

Patient Support Group

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