Step 1: Information
Denotes required fields
*
First Name
Required
Last Name
Required
Date of Birth
Required
Date format: mm/dd/yyyy and must be before today
Email
Required
Incorrect Format
How did you hear about St. Luke's Bariatric Services?
Radio
Newspaper
Physician
Website - St. Lukes
Brochure or Poster
Billboard
Former Patient
Insurance Company
St. Luke's Employee
Realize Band website
Lapband.com
Television
Other
You must select an option.
Step 2: Questions
1. What are some causes of obesity?
a. Physiological – genetics, gender, and evolution
b. Environmental – technology
c. Behavioral – addiction, food to comfort or as a reward, family traditions
d. All of the above
Required
2. Obesity increases your risk of death
a. True
b. False
Required
3. What is the definition of BMI?
a. Blood/Muscle Interpretation
b. Brain Motor Index
c. Body Mass Index
d. None of the above
Required
4. What does your BMI have to be in order to qualify for surgery?
a. BMI 35-39.99 with a comorbid or medical condition related to obesity
b. BMI (≥) greater than or equal to 40
c. BMI (≥) greater than or equal to 30
d. Both a & b
Required
5. You can not have bariatric surgery at St. Luke’s if you have:
a. Ongoing drug or alcohol abuse
b. Untreated or under treated mental illness
c. Diagnosis of Schizophrenia
d. All of the above
Required
6. Which 2 bariatric procedures are primarily restrictive procedures?
a. RNY bypass & sleeve gastrectomy
b. Adjustable gastric band and sleeve gastrectomy
c. Adjustable gastric band and RNY gastric bypass
d. None of the above.
Required
7. What are some examples of possible complications after surgery?
a. Blood clots, staple line leak and muscle weakness
b. Blood clots, infection, dehydration and band slippage
c. Blockage of intestines, band erosion and tremors
d. All of the above
Required
8. What are the requirements of the St Luke’s Hospital Bariatric Program?
a. Dietary & behavioral health evaluation, support group attendance, cardiac and sleep consultation, a letter from your primary care physician (or other physician regularly caring for you) and discontinuation of all tobacco.
b. Dietary and behavioral health evaluation only
c. Cardiac and Sleep consultation only
d. None of the above
Required
9. Once the surgery is performed, I do not have to do anything else. The weight loss will just happen.
a. True
b. False
Required
10. I will need to pay out of pocket expenses, if I have any, up front before my surgery will be scheduled?
a. True
b. False
Required
11. I, as the patient, should call my insurance company and verify that I have the benefit for weight loss surgery.
a. True
b. False
Required
12. Most patients having weight loss surgery at St. Luke’s will go home the day after surgery?
a. True
b. False
Required
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