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CHA Bariatric Surgery Form
Disclaimer: I affirm that I have watched and understand the Bariatric Surgery Online Orientation
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Yes
No
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Please click here to watch the bariatric surgery orientation before taking the quiz
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Name
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First Name
Last Name
Date of Birth
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-
Month
-
Day
Year
Date
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Email
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example@example.com
Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Name of Your Health Plan
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Health Plan ID/Group Number
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Who referred you to our program?
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How did you hear about our program?
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What is your height?
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What is your weight?
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Have you ever had weight loss surgery before?
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Yes
No
If you have had weight loss surgery before what and when did you have done?
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What is your gender?
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Take the Quiz
Obesity is a disease of excess fat storage with a number of associated diseases, known as co-morbidities.
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True
False
Obesity is a chronic disease.
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True
False
Some co-morbid conditions are:
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Gastroesophageal reflux disease, Degenerative joint disease (DJD), Heart disease, Gallstones, Fatty liver disease, Coronary artery disease, Stroke, Cancer, Osteoarthritis, Infertility
Type-2 Diabetes, Hypertension, Hyperlipidemia, Respiratory disease, Sleep apnea, Asthma/pulmonary disorder, Depression, Menstrual irregularity, Amenorrhea, Dysmenorrhea, Urinary stress incontinence
All of the Above
"Morbid Obesity" is defined as:
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More than 200% of ideal weight or more than 100 pounds overweight
Body Mass Index of 40 or higher
Body Mass Index of 35 to 39.9 with one or more severe co-morbid conditions
All the Above
The type(s) of Bariatric Surgery performed at the Cambridge Health Alliance is/are:
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Roux-en-Y Gastric Bypass
Gastric Sleeve
All the Above
Which procedure is a restriction only procedure?
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Gastric Bypass
Duodenal Switch
Gastric Sleeve
The Gastric Sleeve is not reversible.
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True
False
The Roux-en-Y Gastric Bypass is making a smaller stomach pouch and rerouting the intestines.
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True
False
Which procedure is a combination procedure?
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Adjustable Gastric Band
Gastric Sleeve
Roux-en-Y Gastric Bypass
What are some factors to help you make a decision for which procedure is right for you?
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Age, health risk (depending co-morbidities), amount of weight to lose, lifestyle, and eating behaviors
Decision between you and your surgeon
Both A and B
Ask Your Questions Here (Optional)
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