Surgical Weight Loss Questionnaire

Are you ready to take the first step on your weight loss journey? Fill in our questionnaire below to get started!

The purpose of this form is to provide us with basic information to get you started in our program. There is no cost, commitment, or obligation in filling out this form. Any information you provide to us is kept confidential. If you prefer, you can call us at (828) 327-9178.

* Required

Title Dr Miss Mr Mrs Ms
First Name *	Last Name *
Email Address *
Home Address *	City *
State *	Zip code *
Home Phone Number *	Alternate Phone Number
Date of Birth *
Which procedure are you interested in? * Gastric bypass        Lap band        Sleeve gastrectomy
Height (inches) *	Weight (pounds) *
Obesity-Related Health Problems (check all that apply) *
None Arthritis Diabetes High blood pressure Sleep apnea Heartburn/reflux High cholesterol/lipids Other (specify)	Urine leakage Depression/anxiety Low back pain Gallstones Asthma Migraines Blood clots
Other health problems
Insurance *
How did you hear about our program? (check all that apply)
Primary doctor Family or friend Newspaper Other (specify)	Radio Television Internet
Other source of referral