Weight Loss Surgery Information Class Questionnaire Question Title * 1. Please provide your information so you can be contacted regarding your interest in weight loss surgery. Name * Address: * Address 2: City/Town: * State: * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP: * Email Address: Phone Number: * Question Title * 2. How did you hear about the weight loss surgery program at St. Mark's Hospital? (Select all that apply) Internet Search (Google, Yahoo) Television Hometown Values Insurance Mailer Flyer Online Ad Radio station Billboard Surgeon's office A friend referred me A physician referred me Facebook Pinterest Other (please specify) Question Title * 3. Which medical conditions are related to obesity? Type 2 diabetes High blood pressure Cancer Sleep Apnea Reflux disease All the conditions above are related to obesity. Question Title * 4. Which of the following contributes to the disease of obesity? Environment Diet and Lifestyle Genetics Behaviors/Psychology Hormones such as Leptin and Grehlin All of the above. Question Title * 5. Our weight loss surgery program offers which of the following weight loss surgeries? (Check all that apply.) Lap Band (including the LAP-BAND system and the REALIZE band system) Sleeve Gastrectomy Gastric Bypass Duodenal Switch Question Title * 6. True or False: Studies have shown that bariatric or weight loss surgery is an effective treatment for metabolic diseases such as diabetes. True False Question Title * 7. Which of the following statements are true regarding weight loss surgery? (Check all that apply.) Weight loss surgery is an easy fix for weight loss. Weight loss surgery is a tool to help patients make positive lifestyle changes for long term weight loss success. You cannot regain weight following weight loss surgery. Weight loss surgery has risks and I must evaluate the benefits and decide if it is right for me. Question Title * 8. What changes must a weight loss surgery patient make for long term weight loss success? (Check all that apply.) Eat a 70% protein, 30% vegetable, low carbohydrate diet after surgery. Eliminate soda, coffee and alcohol from your diet. Eat 3 meals each day. Exercise 30-50 minutes each day. Take vitamins as directed by my surgeon which typically includes a multivitamin and calcium. Question Title * 9. True or False: A lap band is a restrictive procedure that can help an individual lose 40-50% of their excess weight at 5 years. It is adjustable and requires frequent follow up with the surgeon to achieve optimal weight loss. True False Question Title * 10. Which of the following is true regarding a lap band? (Select all that apply.) Safest initial surgery Shorter hospital stay Does not have any long term risks Least expensive, initially but will have to pay for the cost of adjustments May be less stressful on the body Can help with a slower weight loss Question Title * 11. True or False: A sleeve gastrectomy helps you to feel full on less food. Food enters the digestive tract normally. True False Question Title * 12. Which of the following is true of the sleeve gastrectomy? (Select all that apply.) It is reversible. Weight loss is 50-60% of excess weight at 5 years. Risk of a leak from the staple line is 1%. This surgery is not reversible as part of the stomach is removed from the body. Question Title * 13. True or False: The Roux-en-Y gastric bypass is considered the gold standard weight loss surgical procedure because it has been around the longest and is the most studied. True False Question Title * 14. Which of the following is true of the gastric bypass? (Select all that apply.) Helps individuals lose 60-80% excess body weight at 5 years. It resolves 80-90% of diabetes cases within 3 weeks after surgery. It can limit the absorption of some nutrients including calcium, iron and vitamin B12. Risks include leaks, strictures, bowel obstructions, and death. Question Title * 15. True or False: The duodenal switch is the most powerful of the weight loss surgeries offered but also has higher risks. True False Question Title * 16. Which of the following is true of the duodenal switch? (Select all that apply.) Provides the greatest improvement in triglyceride levels. Is a malabsorptive surgery that requires you to take additional vitamins. Provides 70-90% of excess weight loss at 5 years. Risks include leaks, bowel obstruction, malnutrition, diarrhea, foul smelling flatus, protein malnutrition, and fat soluble vitamin deficiencies You do not have to follow up with your surgeon frequently. Question Title * 17. I have watched all of the weight loss surgery videos and understand that weight loss surgery has risks. I have researched this decision and believe that this is the right direction for me and my health. Yes No Question Title * 18. Please let us know if you have any other questions by emailing the St. Mark's Weight Treatment Center directly at STMH.WEIGHTLOSS@HCAHealthcare.com Thank you for completing our online weight loss surgery seminar. If you have decided that surgery is right for you, please follow call the weight treatment center and schedule your appointment. Weight Loss Surgery:The next step is to fill out the patient information form completely and send it into our office {FAX 801-268-7622}. Please include a copy of your health insurance card if you will be using your health insurance to help pay for surgery. The contact information for the Weight Treatment Center office is 801-268-7622 or STMH.WEIGHTLOSS@HCAHealthcare.com.Once your paperwork is turned in, the office will contact your insurance company to verify your benefits and let you know what criteria has to be met to get a pre-approval for surgery. If you are needing a supervised diet, nutrition evaluation or a psychological evaluation, the St. Mark’s team can help you complete those requirements. To schedule an appointment with them call 801-268-7479.Katie Stokes, MSN, FNP-BC also offers non-surgical weight loss options at St. Mark's Hospital. Please let me know if you have any other questions about weight loss surgery. We look forward to working with you!Garth Hunt, MPH, RDSt. Mark's Weight Treatment CenterGarth.Hunt@Mountainstarhealth.comOffice: 801-268-7479 Done