Are you the right candidate for LAP-BAND Surgery?
International Laparoscopic Obesity Surgery Team (ILOST)
Bariatric Patients Pre-Qualification Form

Please complete the following form. Any medical, or personal information you provide will be kept absolutely confidential.
* are required fields
*Name: Phone: - -
*Address: *Email:
*City/State/Zip: Occupation:
*Date of Birth: Month Date Year *Sex: Female Male
*Height: ' "  or   m cm *Weight: lb.  or   kg
Family History of Obesity:   Parent Yes No    Sibling Yes No
Please check as many of the options that apply to you, and provide your comments in the Other remarks box below.
Cardiovascular: High Blood Pressure
Heart Attack
Stroke
Heart Failure
Chest Pain When Walking
Varicose Veins
Phlebitis-Pulmonary Embolus
Respiratory: Chronic Cough/Emphysema
Asthma
 Sleep Apnea: Mild Severe
Gastrointestinal: Hiatus Hernia and/or Heartburn
Stomach Ulcers
Gallstones
Chronic Constipation
Blood with Bowel Movement
Previous Surgery
 Dentures: Full Upper Lower Partial
Gynecological: Pregnancies
Premenstrual Bleeding
 Menstrual History: Regular Irregular
Endocrine: Thyroid
Diabetes
Diabetes Therapy (diet/pills/insulin)
High Cholesterol/Triglycerides
Other Endocrine
Psycho/Social: Eating Disorders (e.g. eat too much)
Consultation or Therapy
Musculo-Skeletal:
 Joint Pain: Hips   Knees   Ankles   Lower Back
 Arthrosis: Hips   Knees   Ankles   Lower Back
Any other diseases: Neurological
Urinary
 Any other diseases:
Drugs: Diet pills (e.g. Phen/Fen)
Substance Abuse
Smoking
 Alcohol drinks/day:
Medications: Prescribed
Please list:

Self-Administered (e.g. Aspirin)
Please list:
Allergies: Food
Please list:

Medications
Please list:
Previous diets you have followed:

When?
Weight Lost? lb.   Weight regained? lb.
Your timeframe for surgery? Immediately 3-6 Months 6-9 Months
Are you interested in financing options?
Please send me information.
No, I'm not interested.
Other remarks:




For more information on the LAP-BAND procedure, contact us at
info2@obesitylapbandsurgery.com

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