Step 2: Complete the Screening Questions
First Name
*
Last Name
*
Date of Birth
*
Email
*
Phone Number
*
Height
*
Weight
*
Where would you like to go for your surgery appointments?
*
Please Select
BMC in Springfield
BFMC in Greenfield
Not sure
What are the two types of bariatric surgery we perform?
*
Please Select
Gastric Bypass and Gastric Band
Sleeve Gastrectomy and Gastric Bypass
Gastric Band and Sleeve Gastrectomy
Who is your first appointment with?
*
Please Select
Behavioral Health
Dietitian
Physicians Assistant PA
Surgeon
Who are the key players on the bariatric team?
*
Please Select
Behavioral Health, Nutrition, Cardiology
You, The Medical Team, Nutrition, Behavioral Health
Cardiology, Nutrition, The Medical Team
True or False: Weight loss surgery is considered elective
*
Please Select
False
True
Are you required to quit smoking?
*
Please Select
No
Yes
The Baritastic App will help you through this journey. Which of the following does the app NOT do?
*
Track food
Set reminders
Track steps
Provide access to recipes and support groups
Schedule appointments
True or False: Weight loss surgery risks include nausea, vomiting, and dehydration.
*
Please Select
False
True
True or False: You will need to take supplements for the rest of your life after surgery.
*
Please Select
False
True
True or False: After weight loss surgery you are more likely to become pregnant unexpectedly.
*
Please Select
False
True
Which bariatric surgery video did you watch?
*
Please Select
English
Spanish
Type your first and last name as agreement that you have watched this video in full.
*
Submit
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