Patient Assessment - weight loss surgery

1

Are you?* This field is required.

Male

Female

2

What is your height (inches)?

3

What is your weight?

4

Have you tried any of these to lose weight?Select from below.

Structured Weight Loss Programs (ex. Weight Watchers)

Diets (ex. Keto, NSNG, Atkins)

Exercise Programs

Medical Weight Loss

More than one of these

All of the above

5

Do you have any of these symptoms?Select the one that causes you most difficulty.

Joint pain

Out of breath quickly

Health problems (Diabetes, Sleep Apnea)

Depression and self image

All of the above

6

Why do you want to lose weight?Select your biggest reason.

Play with your children or grandchildren

Improve self image

Improve your health and live longer

Get off meds and have more energy

All of the above

7

What are your fears or concerns about weight loss surgery?

Is the surgery safe?

Can I afford it?

Will I gain all the weight back?

Will I be able to eat normal food?

All of the above

8

Thanks, you may be a candidate for weight loss surgery!Enter your information below to receive your personalized results by email.

First and Last Name

Email Address

Phone Number