Full Name
*
First Name
Last Name
Gender
*
Male
Female
Age
*
Height & Weight Information
*
Imperial (lbs, ft/in)
Metric (kg, cm)
Height (Feet' Inches")
*
Please Select
4'10"
4'11"
5'0"
5'1"
5'2"
5'3"
5'4"
5'5"
5'6"
5'7"
5'8"
5'9"
5'10"
5'11"
6'0"
6'1"
6'2"
6'3"
6'4"
6'5"
6'6"
6'7"
6'8"
6'9"
6'10"
6'11"
7'0"
Weight (lbs)
*
Height (cm)
*
Weight (Kg)
*
Your BMI:
Your BMI is:
Have you had any previous bariatric surgeries?
*
Yes
No
Procedure of Interest
*
Please Select
Gastric Sleeve (VSG)
Gastric Bypass (RNY)
Mini-Gastric Bypass (MGB)
Duodenal Switch/SADI-S (DS)
Single Incision Gastric Sleeve (SILS)
Endoscopic Sleeve Gastroplasty (ESG)
I’m not sure / Need a recommendation
How many previous weight loss surgeries have you had?
*
Please Select
1
2
3 or more
Which was your most recent bariatric procedure?
*
Please Select
Gastric Sleeve (VSG)
Gastric Bypass (RNY)
Mini-Gastric Bypass (MGB)
Duodenal Switch (DS)
Gastric Lap band (LAP-Band)
Revision Surgery (Adjusting a prior bariatric surgery)
Date of most recent procedure
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Specify your desired conversion
*
Conversion to Gastric Sleeve
Conversion to Gastric Bypass
Conversion to Duodenal Switch (SADI-S)
I’m not sure / Need a recommendation
Reason for seeking a revision
Weight regain
Reflux / GERD
Malnutrition / Vitamin deficiency
Excessive weight loss
Insufficient weight loss
Other
Please Specify
Were any of your weight loss surgeries performed via an open incision?
*
Yes, Open Incision
No
Have been diagnosed with?
Rows
Yes
No
Asthma/Respiratory Issues/COPD
High Blood Pressure (Hypertension)
Pre-diabetes/Type 1 or 2 Diabetes
Sleep Apnea
Heart Disease / Arrhythmia
Thyroid Disorder (Hypo/Hyperthyroidism)
GERD / Acid Reflux
Fatty Liver Disease
Heart Disease?
Heart Disease / Arrhythmia Details
*
Have you ever tested positive for HIV or Hepatitis?
*
Yes
No
Lifestyle & Current Care
Rows
Yes
No
Do you currently smoke? (Vaping/Tobacco)
Do you drink alcohol? (Regularly +2/wk)
History of blood clots? (DVT/Pulmonary Embolism)
Do you take blood thinners?
Do you use any Recreational Substance (eg. marijuana, others)
Use Drugs?
Recreational Substance Use
Current medications & dosages
Have you had any prior abdominal surgeries (excluding weight loss)?
Were any of these procedures performed as 'open' surgery?
YES, Open Incision
No
Any known surgical conditions you would like Dr. Sandy to address?
Yes
No
Additional Surgical Procedures
Please Select
Hiatal Hernia Repair
Gallbladder Removal (Cholecystectomy)
Umbilical Hernia Repair
Adhesiolysis (Scar Tissue Removal)
Incisional Hernia Repair
Base_Cx
Base_BMI
Base_Rev
Extra_1
Extra_2
Extra_3
Extra_4
Extra_5
VACIO
Email Address
*
Phone Number
*
Select your US State
Do you have a surgery date in mind?
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Do you have a timeframe in mind for your surgery?
Please Select
As soon as possible
Within 1–3 months
Within 3–6 months
Not sure yet
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