For the Following Questions, Please Indicate "Yes" "No" or "Do Not Know".
Please answer all of the questions.
1. Do you currently take any of the following medications?
a) Aspirin (excedrin, anacin, bufferin)
b) Anticoagulants (blood-thinning medicine)
c) Propanol, Verapamil (heart rhythm medicines)
d) Diuretics (water pills)
e) Antihypertensive drugs (blood pressure pills)
f) Digitalis (heart pills)
g) Stereoids (prednisone, cortisone)
2. Have you ever been treated for cancer with
chemotherapy or radiation therapy?
If yes: when:
3. Do you currently have any problems with your:
a) Liver (e.g. cirrhosis, hepatitis, yellow jaundice)
b) Kidneys (infection, stones, failure)
d) Blood (anemia, leukemia)
4. Have you or anyone in your family ever had
a serious bleeding problem?
5. Have you ever had prolonged or unusual bleeding from
tooth extractions, cut, surgery or nosebleed?
6. Do your gums bleed when you brush your teeth?
7. Are you pregnant?
8. Is there any possibility that you are pregnant?
9. Have been told you have diabetes?
10. Do you wake up to urinate more than once at night?
11. Do you have muscle cramps or pains?
12. Do you have problems with your lungs or chest? (e.g., chest pain,
skipped heart beats, high blood pressure, smoke one or more packs a day,
shortness of breath, emphysema, asthma, bronchitis) if yes please list:
13. Do you have a cough, or cough frequently?
14. Do you have epilepsy or suffer from fits or seizures?
15. Do you have neck or back problems?
16. Are you scheduled to have an operation?
If Yes, what operation?
17. Are you currently taking any medications?
If Yes, please list:
The recommended surgery for obese patients with GERD or severe acid reflux is the Gastric Bypass. The bypass is the anti reflux surgery for weight loss. The sleeve can actually cause more reflux that may or may not be controlled with medication. In the case that the reflux is not controlled by medication you will need to consider converting your sleeve into a gastric bypass to prevent serious repercussions from the acids