Lap Band Surgery Application

 

* Indicates a required answer.

For us to respond in a timely manner, please include your email address if you have one.

Patient Information
*Name
Email (required for additional information you need to receive from us about lap banding)
*Birth Date
*Address (Street, PO Box)
*City
*State/Province
*Zip/Postal Code
*Telephone
*Name of person to contact in case of an emergency
*Emergency Telephone #
Desired Date of Surgery
   
 
Medical History
*Height
*Weight lbs
*BMI (Click HERE to use Inamed's BMI calculator.)
*Do you smoke (Yes/No)?      If Yes, How much?  
 
Do you CURRENTLY have any of the following conditions? (Please click in the appropriate blocks)
YES NO Condition
Diabetes Mellitus     If yes, how long?  
Hypertension (High blood pressure)
Sleep Apnea (Stop breathing during sleep)
Gastroesophageal Reflux (Heartburn)
Gallbladder Attacks (Click NO if removed)
Heart Attack or Coronary Disease or Angina
Obsessive Compulsive Disorder
Anorexia or Bulemia
Lower Extremity Swelling
Shortness of Breath Upon Exertion
Depression
Joint Pain
Urinary Stress Incontinence
Asthma
 
Have you EVER had any of the following conditions or diseases? (Please click in the appropriate blocks)
Auto-Immune Syndrome Hernia
Anemia High Cholesterol
Appendicitis Kidney Disease
Bladder/Prostate Problems Liver Disease
Bleeding Disorders Migraine Headaches
Cancer Pneumonia
Chemical Dependency Psychiatric Illness
Circulation Problems Rheumatoid Arthritis
Colon Problems Stomach Ulcers
Emphysema Stroke
Epilepsy Thyroid Problems
Heart Disease Tuberculosis
Hepatitis Problems with the Esophagus
 
General Medical History (Please type your answer or click in the appropriate blocks)
*List All Medication allergies
List all Medications or herbal supplements you are currently taking that were not specified above (please list the name, dosage and reason for this medicine)
List all abdominal surgeries (i.e.: gallbladder, appendix, hernia, etc.)
Do you have dentures, dental implants, or caps?( if yes, please indicate where)
YES NO  
Have you ever had previous obesity surgery? 

If YES, what type?

When?

Have you received physician supervised treatment for obesity? If YES, list physicians and approximate dates.

Have you ever taken Phenteramine (Fastin, Adipex, Phen-fen)?
Have you ever taken Xenical?
Have you ever taken Meridia?
Have you ever taken any other medications for weight loss? If YES, please list.

Have you ever attended a support group for obesity? If YES, where?

Have you ever had a reaction to local or general anesthesia? If YES, please state the reaction.
Have you ever had a blood transfusion?
General Remarks, Comments, Questions, etc.
How did you hear about this web site (who referred you, what search engine did you use, what bulletin board, etc.)?
 

Please click on the Submit button only once. You should see a response within a few seconds.

Note: If you do not get a response back within 48 hours, please send am email to:

Barbara.mg31@gmail.com


 

 

 
 
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