surgeryNC

Bariatric Specialists of NC

Weight Loss History

Height______Current Weight______Body Mass Index (BMI) ______

·  Please select the procedure you are interested in:

___Laparoscopic Roux-en-Y Gastric Bypass ___Lap-Band

___Laparoscopic Sleeve Gastrectomy ___Realize Band

___Revision ___Undecided

___Other (describe) ______

·  How many years have you been at your current weight?______

At what age did you become obese? ______

What was your lowest weight over the past 5 years? ______

What was your highest weight over the past 5 years?______

What is your desired weight? ______

·  Please check any previous weight-loss surgery** that you’ve had and the year you had it:

______Vertical Banding Gastroplasty

______Lap-Band™

______Mini Gastric Bypass

______Roux-en-y Gastric Bypass

______Stapling (or other restrictive procedure)

______Other (please describe): ____________

**Please note: If you have had previous weight loss surgery, you must obtain your operative records from the surgeon or the hospital where the procedure was performed and provide them to our office.

·  Have you ever had a sleep study? Y N

If yes, when and where did you have the sleep study?______

Are you currently using a CPAP?______

·  Please place a check beside any previous weight-loss methods used:

Atkins / LA Weight Loss / Obinex / South Beach Diet
Body for Life / Liquid Diet / Phen-Fen* / Starvation
Cabbage Diet / Low-calorie diet / Physician Weight Loss / Susan Powters
Dexatrim / Low-carb diet / Redux / TrimSpa
Exercise / Low-fat diet / Richard Simmons / Weight Watchers
Grapefruit Diet / Meridia / SlimFast / Xenedrine
Hollywood Diet / Metabolife / Somersize / Xenical
Jenny Craig / Nutrisystem / Soup Diet
Other (please describe):
* If you took Phen-Fen, please enter date and type:

Name (printed):______Date of Birth: ______

Signature:______Date:______

Revised 4/2011:mpw