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	None Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming Alberta British Columbia Manatoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon
*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.)?

 

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