Dr. Ponce

Call us at:
[619] 754.4962

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Eligibility Questionnaire Print E-mail

The information submitted by you is privileged and confidential,
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
----------------------

 
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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