Please print this document and complete the following examination, answering
each question carefully. Your answers will help us to be certain that you fully understand the information which has
been provided to you about your operation, and to point out to us what needs to be clarified and explained to you further.
Please circle either "True" or "False" for each question.
1. Your first
Lap-Band adjustment will be done in the hospital immediately following surgery to "jumpstart" your weight loss.
True or False
2. There are no other operations or programs for obesity available, except for laparoscopic
adjustable gastric banding (Lap-Band).
True or False
3. Erosion, slippage, a leak in the implant, and
infection may occur in Lap-Band cases.
True or False
4. Clots may form in the legs or pelvis, which
can break off and float into the lungs. These can cause breathlessness or chest pain and they can also be fatal.
True or False
5. It is important to exercise and to avoid snacks after having the Lap-Band surgery.
True or False
6. After Lap-Band, patient's are guaranteed to permanently lose weight.
True
or False
7. Diabetes, high blood pressure, back pain, and similar ailments always get better after obesity surgery.
True or False
8. When serious complications occur, Intensive Care, for short or long term, may be necessary.
True or False
9. Re-operation may be necessary due to bleeding, ulceration, bursting of stitches, erosion,
slippage, leakage, or infection.
True or False
10. Lap-Band surgery is a cure for obesity and afterwards,
patient's can lead a normal life without regular medical care.
True or False
11. Lap-Band adjustments
to increase or decrease the size of the pouch opening will be done in the surgeon's office whenever you ask for one, based
on weight gained/lost and other symptoms.
True or False
12. I can still drink 2-3 cans of soda or carbonated
juices, or alcholic beverages after my surgery, as long as it is in moderation.
True or False
13. Obesity
surgery is an easy operation and not a very serious or risky procedure.
True or False
14. Patient's
never feel nauseated or vomit after placement of the Lap-Band.
True or False
15. Complications
only occur in the hospital. After discharge, medical problems are unlikely, so it is important not to bother the doctor
with minor problems.
True or False
16. Surgery has nothing to do with emotions, so dangerous depressions
cannot occur after obesity surgery.
True or False
17. Patient's can be quite uncomfortable or miserable
for the first 48 hours after surgery.
True or False
18. After Lap-Band surgery, a person can eat as
much of any kind of food as he/she wants, and not gain weight.
True or False
19. In the United States,
approximately 1 out of 2000 patient's who have laparoscopic adjustable gastric banding ( Lap-Band) surgery die.
True or False
20. After the Lap-Band procedure, I can have the band adjusted to be able to eat more for a special
occasion, like a wedding.
True or False
The following questions will verify that you have received
information from various sources regarding the Lap-Band, prior to your surgery. Please circle yes or no.
1. I
attended an informational seminar by my surgeon.
Yes or No
2. I have reviewed an informational video,
or powerpoint presentation regarding laparoscopic adjustable gastric banding (Lap-Band).
Yes or No
3.
I have talked to at least one other person who has had the surgery
Yes or No
4. I have received printed
information from this office before surgery.
Yes or No
5. I know that I must attend bariatric bootcamp
at AtlantiCare Regional Medical Center prior to my surgery.
Yes or No
I certify that I have answered
all questions on this form honestly, without any help from anyone else in answering any questions. I understand
that a score less than 16 correct will require me to return to my surgeons educational seminar, be re-evaluated for my understanding
of this surgery, and then re-take this questionairre with a passing score to be scheduled for my surgery.
Patient Name: ________________________________________ Date: _________________
Patient
Signature: _____________________________________________________________
Incorrect answers
reviewed and clarified to the patient by the surgeon.
Physician Signature: ________________________________________
Date: ______________
