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Follow-up questionnaire

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Bloc formulaire

Fields marked with an asterix are required.

Last Name *

First Name *

Surgeon's name

Current weight

Specify in pounds or kilograms

Do you suffer from gastric reflux?

Do you suffer from heartburn?

Are you taking any medicine for the stomach?

Do you feel that food is blocking when you eat?

Do you have nausea?

Do you experience vomiting?

Do you have any other pain or discomfort?

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Do you have hypoglycemia?

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Do you suffer from intestinal disorders?

Among the following, select those you take on a regular basis?

Multi vitamins (e.g: Centrum) Vitamin D Calcium Calcium + vitamin D Iron Vitamin B12 Vitamin A

During meals, how much solid food are you able to eat?

On average, how many meals do you eat each day?

On average, how many snacks do you eat each day?

On average, how many physical activity sessions lasting over 20 minutes do you perform each week?

Do you have one or more renewals to complete?

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