LapbandCost.com - Eligibility Questionnaire

Written by Administrator

Tuesday, 02 May 2006

The information submitted by you is privileged and confidential,
Obesity Goodbye does not distribute or sell this information to 3rd parties, as it is used strictly for internal purposes.

	Title:

	First name :

	Last name:

	email:

	confirm email:

	State:

	State for non US residents:

	Country:

	Phone Number:

Date of birth :

Month	Day	Year

Enter Your Weight: :	pounds:
Enter Your Height::	feets:	inches :

	Your BMI:

Medical History:

	(ej. Allergies, Hospitalizations, Previous surgeries)

Obesity related problems:

	yes	no
Diabetes
Hypertension:
Bone problems:
Depression:
Sleep disorders
Physical condition
Digestive System
Heart & circulatory system
Respiratory problems
Compulsive eating
Low expectations
Isolation
Gastro Esophageal Reflux

	Do you have Hiatal Hernia :
	yes	no

	If you answered yes, are you in treatment, what is your treament?

	Other:

	What kind of diets have you carried out? (how long?):

Wish date for surgery:

Month	Day	Year

	How did you find about us?: Please, provide us with this information so we can enhance our services.

	Who is your patient coordinator :

Last Updated ( Wednesday, 06 February 2008 )

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