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LAGB Evaluation Form
Evaluation Form / Patient Questionnaire for LAGB (Gastric Band or Gastric Balloon) Candidates

In order to evaluate your suitability for the weight reduction procedure or surgery (Gastric Band or Gastric Balloon) please complete this form and provide as much as information you can.
Contact Information
*First Name :
*Last Name :
Address :
*Email Address :
Telephone Number :
Mobile Number :
Prefer time to contact :
Biography
*Age :
*Gender : Male       Female
*Marital Status :
City :
No. Of Children :
Occupation :
Weight History
*Current Weight : kg
*Height : cm
*Max. weight ever : kg
Body mass index (BMI) :
Obesity started in : Childhood       Puberty       Recent       Years
Other family member obesity : Yes       No
Motive to lose weight :
Serious attempts at dieting : Yes       No
Life and work stressors : Yes       No
Do you frequently feel sad : Yes       No
Crying spells : Yes       No
Treatment for depression : Yes       No
Excessive guilt feelings after bringing / Ever induce vomiting (Bulemia)? : Yes       No
Sleep Quality :
Hours of TV and computer per day : minutes/day
Exercise : Yes minutes/day       No
Can you easily climb two or three flights of stairs? : Yes      No
Comments regarding exercise :
Past Medical History
Diabetes : Yes       No     Date of onset:
High Blood Pressure : Yes       No     Date of onset:
Chest pain / heart attacks :
Bronchial Asthma : Yes       No
Sleep Apnea : Yes       No
Snoring : Yes       No
Short of breath : Yes       No
Acid burn : Yes       No
Thyroid problems : Yes       No       Never Checked
Menstrual Period : Regular       Irregular
Hepatitis : Yes       No
Bleeding tendency : Yes       No
When was your last physical exam by your doctor? :
Previous gastroscopy / barium swallow (stomach x-ray) : Yes       No
Medications : Yes     List       No
Previous Surgery / General Anesthesia
Any previous in the abdomen : Yes       No
Allergy : Yes     List       No
Diet History
Binger (eats huge amounts in one meal) :
Nibbler (eats all day) :
BOTH binger & nibbler :
Breakfast : Yes       No
Juices : Yes       No
Fizzy drinks : Yes     List       No
Caffeinated drinks : Yes       No
Milk Shakes : Yes       No
Water : Yes     How Much?       No
Alcohol : Yes     How Much?       No
Candy / Sweats / Chocolates / Ice-cream : Yes       No
Fast food-fried meals : Yes       No
Junk food: chips : Yes       No
Meat / Kabsa : Yes       No
Pasta / Pizza / Bread / Rice> : Yes       No
Is your opinion what is the main reason for your obesity? :
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