Dr. Ponce

Call us at:
[619] 754.4962

Eligibility Questionnaire Print E-mail

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Lapband Connection 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
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Body Mass Index Calculator
Weight: 
Height:  o
Age:  years or: 
Gender:
kg / m2
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Medical History:
  (ej. Allergies, Hospitalizations, Previous surgeries)
Obesity related problems:
 yesno
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 :
yesno 
 
 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.
 

 

 
 
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