Weight No Longer - Lap-Band for Life
Frequently asked questions
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 Use this self-assessment form to help you figure out if you need a tightening
of your Lap-Band or if you need to change your eating habits. Print this form, complete it and bring it with you to
your next office visit.
In each section please check off all of the answers that apply to you NOW. Please be honest about your experience so that we
will know how to best help you.
¨ My meals are smaller than ½ cup ¨ My meals are about ½ cup ¨ My meals are larger than ½ cup ¨ I do not eat meals; I graze throughout the day
¨ I am not hungry in between meals ¨ I am hungry between meals but I do not snack ¨ I am hungry between meals and do snack ¨ I eat what I want, when I want it
¨ I can tolerate all foods without difficulty ¨ I cannot tolerate many foods; please list:______________________________________ ¨ I cannot tolerate most foods and eat mostly junk foods (e.g. chips, cookies, ice cream)
¨ I never vomit during or after eating ¨ I sometimes vomit if I have eaten too much or too fast or eat the wrong food ¨ I vomit nearly every time I eat
¨ My hair is falling out ¨ My fingernails are soft and brittle ¨ I am lethargic/tired most of the time
¨ I get regular exercise 3 or more days per week ¨ I am active but do not engage in regular exercise ¨ I never exercise ¨ Other:_______________________________________________________________________
¨ Water is my main beverage ¨ I drink high calorie beverages often ¨ I drink 64 ounces of fluid every day ¨ I do not drink enough because: o I am not thirsty o I can’t fit it in my pouch o I don’t think about it
Protein ¨ I get more than 60 grams of protein every day ¨ I get close to 60 grams of protein every day ¨ I do not get enough protein ¨ I don’t know how to count grams of protein
¨ I take a multivitamin supplement every day ¨ I take calcium supplements every day ¨ I might miss a day or two, but I am pretty good with taking my supplements ¨ Am I supposed to be taking vitamins?
¨ I am still losing weight at an acceptable pace ¨ My weight loss has slowed or stopped ¨ I have gained weight
¨ Change my lifestyle ¨ Have an adjustment because I am living a healthy lifestyle and an adjustment would complement my good habits ¨ Have an adjustment regardless of my lifestyle
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