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BARIATRIC SURGERY SELF ASSESSMENT

Is weight loss surgery the right choice for you? Complete the following quiz and a bariatric nurse will contact you about your options.

ASSESSMENT QUESTIONS
Are you at least 80 pounds overweight?
Do you have any of the following conditions: diabetes, hypertension, GERD (heartburn or reflux), arthritis in weight-bearing joints (knees, ankles, hips, back), high cholesterol, sleep apnea or infertility?
Yes No
Does your weight stop you from doing activities you enjoy?
Yes No
Can you comply with long-term, life-long dietary changes?
Yes No
Are you interested in learning more about surgical weight loss or bariatric medical weight management (can be an option for individuals who are 10-75 pounds overweight)?
Yes No
Enter your current BMI:

Use the calculator below to find out your current BMI.
How did you hear about or find this website?
 
CONTACT INFORMATION
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Email:
Phone:
Street Address:
City:
State:
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All rights reserved.		 1492 S. Mill Ave., Suite 201
                        Tempe, AZ 85281