Lap-Band Surgery for Weight Loss, Weight Control, Weight Reduction & Obesity Treatment

patient profile

If you are considering surgery, please take a few moments to answer the questions below. Then hit submit and Dr. Juan A. Lopez Corvala will review your information to see if you are a likely candidate for the INAMED® LAP-BAND® System.

Your answers will help us to help you with your decision.

Full Name:
Address:
City:
State:
Zip Code:
Country:
E-mail:
Work Phone:
Home Phone:
Date Of Birth:	(mm/dd/yyyy) Age:
Current Weight:	Height:
What is your gender?	Male Female

Do you have any of the following obesity-related conditions?

YES	NO
		Type 2 diabetes (diabetes mellitus).
		High Blood Pressure, coronary artery disease or other circulatory conditions.
		Heart or Vascular disease
		Cerebral Infraction
		Gallstones
		Gastroesophageal Reflux
		Asthma
		Sleep Apnea
		Joint Problems
		Psychological or Social disorders

Do you have any of the following medical conditions?

YES	NO
		Conditions related to the gastrointestinal tract (Crohn's, ulcers, etc.)
		Previous gastric conditions.
		Metabolic conditions. (i.e. hypothyrodism)
		Disease that may have caused you to be Overweight.
		Severe Hiatal Hernia.
		Severe heart, lung or any other disease that makes you a poor candidate for surgery.
		Cirrhosis of the Liver.
		Chronic Pancreatitis.
		Portal Hypertension.
		Autoimmune connective tissue disease.
		Need for a chronic, long-term steroid treatment.
		Addiction to alcohol or drugs.

Have you been overweight for more than 5 years?

YES	NO


Have you ever been on medically supervised weight loss programs, such as supervised diets or prescription drug therapies?

YES	NO


How did you hear about Us?

Lap Band Clinic at Oasis of Hope Hospital