The Mini-Gastric Bypass

       

Studies show the MGB is More Effective than the LAP-BAND®* / Safer than the RNY Gastric Bypass**

 

Online Survey

 
 
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Mini-Gastric Bypass

   

Las Vegas, Nevada 
Dr. Rutledge  Email: DrR@clos.net or
Call Talk to Dr. Rutledge Now at: 702-215-9550
Free

Orlando, Florida 
Dr. Peraglie 
Email: DrP@clos.net or
Call Dr. Peraglie Now at: 407-922-3424
Free

   

Las Vegas
"MGB Angels
"

 
Weight Loss Surgery Online Survey: Please fill out our form even if you haven't had surgery.

Have you had Weight Loss Surgery?

Previous Weight Loss Surgery:   
Surgery Type:   
 
Check if you have had previous weight loss surgery

Month:
Year:
Patient Identification Information:
Today's Date:
First Name
Last Name
Address
City
State
Zip Code
Home Phone
Your Email Address  
Note: Please don't use your work Email address. I suggest you use one of the free services to get an email address just for this purpose. Try http://hotmail.com for example.
May we have your permission to contact you to confirm your results? May we have permission to contact you about your experiences with surgery.  
Would you like an email copy of the results of this survey?
Birth Date
Body Size and Weight Information:
Your Weights before surgery
(Note: If you have not had surgery what have your weights been over the last 5 years?)
Weight 1 Year before surgery ,
2 yrs before surgery:

3 yrs before surgery:
 
4 yrs before surgery:

5 yrs before surgery:
Your Weights after surgery
PreOp Weight:      lbs. Your Weight Now:   lbs.
Weight at 1 mo:    lbs.  Weight at 5 yrs: lbs.
Weight at 3 mo:    lbs.  Weight at 10 yrs: lbs.
Weight at 6 mo:    lbs. 
Weight at 12 mo:  lbs. 
Weight at 24 mo:  lbs.
Weight at 3 yrs lbs.    
Your Waist Measurement
PreOp: inches   Now: inches
Your Height
  feet  inches
Now (After Surgery) Before Surgery
Depression? Were you depressed before surgery?
Do you now have Diabetes?    Did you have Diabetes before surgery? 
     Are you on Insulin now?      Were you on Insulin?
Do you now have shortness of breath?     Did you have shortness of breath before surgery? 
Sleep Apnea Now: Sleep Apnea Before Surgery:
Do you now have high blood pressure?    Did you have high blood pressure before surgery? 
High Cholesterol: High Cholesterol:
Incontinence?  Incontinence before surgery?
Do you now have an ulcer? Did you have a Peptic Ulcer before surgery?
Vomiting one or more times per week Vomiting one or more times per week
Heartburn one or more times per week Heartburn one or more times per week
Has a D r. told you that you have gastroesophageal reflux?  
Are you on medicine for reflux?

Have you had an endoscopy of your esophagus and/or stomach since surgery?

If yes did they find esophagitis?

What kind of esophagitis was found? 

Description of the Endoscopy:
Did you have gastroesophageal Reflux before surgery?
Are you on medicine for reflux?

Did you have an endoscopy of your esophagus and/or stomach since surgery?

If yes did they find esophagitis?

What kind of esophagitis was found? 

Description of the Endoscopy:
Have you had gallbladder surgery after Weight Loss Surgery: Did you have gallbladder surgery before surgery:
Bowel Obstruction:: Bowel Obstruction:
Hernia: Hernia:
Any other post operative Complications?
Your present medications.
Notes (Any other comments)

 

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This notice describes how information about you may be used and disclosed and how you can gain access to this information.  Please review carefully


Contact Information: -Telephones: *** CLOS West: 702-456-4643; Trish Lanman 702-376-3446, Sandy Brubaker 702-376-3647; Jennifer Brubaker 702-376-9339, Dr. Rutledge 702-215-9550; 989-450-8081 Kim Hazen 989-450-8081 *** CLOS Florida: Flo Ballengee 863-899-3463 Wayne Robbins 704-682-1549 Elizabeth Robbins 704-928-6693 Dr. Cesare Peraglie 407-922-3424


Email Us Anytime for Help:
Email: Dr. Rutledge DrR@clos.net, *** CLOS West: Trish Lanman Trish@clos.net, Sandy Brubaker SandyB@clos.net Dr. Rutledge DrR@clos.net, Kim Hazen khazen@clos.net *** CLOS Florida: Flo Ballengee flo@clos.net, Wayne Robbins wr@clos.net Elizabeth Robbins epr@clos.net Dr. Peraglie drp@clos.net


Addresses:
Address: *** CLOS West Office: Dr Robert Rutledge / CELOS, 98 E Lake Mead Parkway Suite 302, Henderson NV 89015, Office 702-456-4643, Office fax: 702-456-1173, Contacts: Trish Lanman 702-376-3446 Trish@clos.net, Sandy Brubaker 702-376-3647 SandyB@clos.net, Jennifer Brubaker 702-376-9339 Jen@clos.net, Dr. Rutledge 702-215-9550 Drr@clos.net Kim Hazen 989-450-8081 khazen@clos.net *** CLOS Florida: 40124 Highway 27, Suite 203, Davenport, FL 33837, Wayne Robbins 704-682-1549, wr@clos.net, Elizabeth Robbins 704-928-6693 epr@clos.net, Dr. Peraglie 407-922-3424 drp@clos.net


Warning: Gastric Bypass Surgery is a MAJOR surgical procedure. It can be associated with significant risks and complications, up to and including death. Weight loss surgery is a rapidly developing area of medicine. Bariatric surgery is filled with controversy. It is very important to take a careful and deliberate approach to considering surgery for the treatment of obesity.  

Disclaimer Notice:-Information on this web site is provided for informational purposes only.
-It is imperative that you consult your own physician regarding the applicability of any opinions or recommendations with respect to your symptoms or medical condition.
-Contact with this web site or Dr. Rutledge over the web site does not constitute a doctor patient relationship and for good quality medical care you must obtain advice and consultation form your own local physician.
-This site is intended as a resource for references on the treatment of obesity for health care professionals and educated consumers.
-The authors and editors have used sources believed to be reliable in their efforts to provide information that is complete and generally in accord with the standards accepted at the time of publication.
-Medical knowledge changes rapidly. In view of the possibility of human error or changes in medical science, neither the authors nor the editors nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herein is in every respect accurate or complete, and they are not responsible for any errors or omissions or for the results obtained from the use of such information.
This information is not medical advice or diagnosis, nor is it to be construed as medical advice, medical information, medical diagnosis, or medical prescription for curing, removing, or preventing any disease, or related symptoms. You must seek the direct assistance, advice and evaluation of your own personal physician before acting on any information found herein. These statements have not been evaluated by the Food and Drug Administration.
-Readers are Strongly encouraged to discuss and confirm the information contained herein with your own physician.
Copyright © 1998 The Center for Laparoscopic Obesity Surgery