Required fields *
Form stimulus Web
Name*
First Name*
Date of birth*
Name of Surgeon*
Dr. Henri Atlas
Dr. Ronald Denis
Dr. Pierre Garneau
Dr. Radu Pescarus
Date of operation*
Type of Surgery*
sleeve-gastrectomy
gastric-band
gastric-bypass
biliopancreatic-diversion
other
Current weight*
Lbs
Kgs
Starting weight*
Lbs
Kgs
Diabetes*
never had
improved
cured
insulin
pills
Improved sleep apnea*
never had
yes
no
no apnea
Feeding difficulties*
yes
no
liquid
solid
other
Hypertension*
improved
cured
never had
Reflux:*
before operation *:
yes
no / after opération *
yes
no
Reflux improved with medication*
yes
no
Hunger between meals*
yes
no
Satiety at the end of the meal*
yes
no
Exercise*
yes
no
Comment
Email*
send