(Required, Use Only One, Note: Do not use your work email, No Email?
Click Here for a Free Email Address)
Please give permission to publish your Email address?
Please, strongly
consider giving us permission to allow others to contact you about your
experiences with the Mini-Gastric Bypass. Please remember when you were in
the same situation of considering this surgery.
Birth Date
(mm/dd/yyyy)
Age (Years,
REQUIRED)
Gender
Race, Ethnicity
Your MGB Surgery Date
Body Size and Weight
Information:
Your Weights:
Note: If you are not
sure give your best estimates
PreOp Weight:
lbs.
Your Weight Now:
lbs.
Weight at 1 mo:
lbs.
Weight at 3 mo:
lbs.
Weight at 6 mo:
lbs.
Weight at 12 mo:
lbs.
Weight at 24 mo:
lbs.
Weight at 36 mo:
lbs.
Your Waist Measurement
PreOp:
inches
Now:
inches
Your Height
feet
inches
Now (After Surgery)
Before Surgery
How
many times have you been hospitalized in the year
after your MGB?
How
many times were you hospitalized in the year before your MGB?
What were
you hospitalized for after your MGB?
What were
you hospitalized for before your MGB?
Depression ?
Were you depressed before surgery?
Do you now have Diabetes?
Did you have Diabetes before surgery?
Are you on Insulin now?
Were you on Insulin?
Do you now have shortness of breath?
Did you have shortness of breath
before surgery?
Sleep Apnea Now:
Sleep Apnea Before Surgery:
Do you now have high blood pressure?
Did you have high blood pressure
before surgery?
High Cholesterol:
High Cholesterol:
Incontinence?
Incontinence before surgery?
Do you now have an ulcer?
Did you have a Peptic Ulcer before
surgery?
Vomiting one or more times per week
Vomiting one or more times per week
Heartburn one or more times per
week
Heartburn one or more times per
week
Has a Dr. told you that
you have gastroesophageal reflux?
Are you on medicine for reflux?
Have you had an endoscopy of your esophagus and/or stomach since surgery?
If yes did they find esophagitis?
What kind of esophagitis was found?
Description of the Endoscopy:
Did you have
gastroesophageal Reflux before surgery?
Are you on medicine for reflux?
Did you have an endoscopy of your esophagus and/or stomach
since surgery?
If yes did they find esophagitis?
What kind of esophagitis was found?
Description of the Endoscopy:
Have you had gallbladder surgery after
MGB:
Did you have gallbladder surgery
before surgery:
Bowel Obstruction::
Bowel Obstruction:
Hernia:
Hernia:
Any other post operative
Complications?
Have you had Prior Obesity Surgery? (other than
the MGB)
Previous Obesity Surgery:
Surgery Type:
Year:
Number of Different medications
you took PreOp. (Not counting vitamins and
supplements)
Number of Different medications
you take now. (Not counting vitamins and
supplements)
Total Number of
pills you took
per day PreOp. (Not counting vitamins and
supplements)
Total Number of
pills you take
per day now. (Not counting vitamins and
supplements)
Your PreOp medications.
(Not counting vitamins and supplements)
Your present medications.
(Not counting vitamins and supplements)
Your Present Doctor:
Doctor's name?
Street address.
Doctor's City?
Doctor's State.
Zipcode.
Telephone #.
Doctor's Fax #
How far do you live from your
MGB Dr.?
Less than 1 hour
1-4 hours
More than 4 hours
How much total time did you spend
talking with your MGB Dr. before surgery?
1-30 minutes 31-60 minutes
61 minutes or more
How many times have you been in contact with
your MGB Dr. since surgery?
One time 2-3
times 3-6
times more than 6
times
Were you satisfied with your weight loss surgery?
Yes
No
Was your Medical Doctor satisfied with your Weight Loss
Surgery?
Yes
No
Other Comments:
Notes (Any other comments)
Please Rate your Surgeon
Very High
High
Average
Low
Very
Low
Not
Applicable/Cannot Rate
Professional knowledge & technical capabilities
Ability to explain things understandably
Responsiveness to my concerns
Amount of time spent with me
Friendly and caring approach (bedside manner)
Capacity for gentleness
Please note any other comments about
your surgeon
This notice describes
how information about you may be used and disclosed and how you can gain access
to this information.Please review carefully
Contact
Information:-Telephones: *** CLOS West: 702-456-4643; Trish Lanman 702-376-3446, Sandy Brubaker 702-376-3647; Jennifer Brubaker 702-376-9339, Dr. Rutledge 702-215-9550; 989-450-8081 Kim Hazen 989-450-8081 *** CLOS Florida: Flo Ballengee 863-899-3463 Wayne Robbins 704-682-1549 Elizabeth Robbins 704-928-6693 Dr. Cesare Peraglie 407-922-3424
Email Us Anytime for Help:
Email: Dr. Rutledge DrR@clos.net, *** CLOS West: Trish Lanman Trish@clos.net, Sandy Brubaker SandyB@clos.net Dr. Rutledge DrR@clos.net, Kim Hazen khazen@clos.net *** CLOS Florida: Flo Ballengee flo@clos.net, Wayne Robbins wr@clos.net Elizabeth Robbins epr@clos.net Dr. Peraglie drp@clos.net
Addresses:
Address: *** CLOS West Office: Dr Robert Rutledge / CELOS, 98 E Lake Mead Parkway Suite 302, Henderson NV 89015, Office 702-456-4643, Office fax: 702-456-1173, Contacts: Trish Lanman 702-376-3446 Trish@clos.net, Sandy Brubaker 702-376-3647 SandyB@clos.net, Jennifer Brubaker 702-376-9339 Jen@clos.net, Dr. Rutledge 702-215-9550 Drr@clos.net Kim Hazen 989-450-8081 khazen@clos.net *** CLOS Florida: 40124 Highway 27, Suite 203, Davenport, FL 33837, Wayne Robbins 704-682-1549, wr@clos.net, Elizabeth Robbins 704-928-6693 epr@clos.net, Dr. Peraglie 407-922-3424 drp@clos.net
Warning:
Gastric Bypass Surgery is a MAJOR surgical procedure. It
can be associated with significant
risks and complications, up to and including death.Weight loss surgery is a rapidly developing area of medicine.
Bariatric surgery is filled withcontroversy. It
is very important to take a careful and deliberate approach to considering
surgery for the treatment of obesity.
