Surgical Weight Loss Screening Questionnaire

Please fill in the blanks on the form below, then click on the “Submit” button at the bottom of the page. Be sure to provide as much detail as you can.

If you prefer, you can get a screening questionnaire by mail - simply call us at (828) 327-9178.

Your Choice

Which procedure are you interested in? (you may check either one or both)
Gastric Bypass Lap Band
Which hospital would you prefer?
Catawba Valley Medical Center Frye Regional Medical Center Either would be fine

Personal Information

Your Name(required)
Email(valid email required)
Full street address(required)
Home phone (with area code)(required)
Work phone (with area code)
Date of birth(required)
Gender
Male Female
Height (feet) (required)
Height (inches) (required)
Weight (pounds)(required)
How long have you been overweight?(required)
How long have you been at or near your current weight?(required)

Additional Information

How did you hear about our program?
Primary doctor Family or friend Newspaper Radio Television Internet (specify) Other (specify)
Other source of referral (please provide details)
For security, please type the verification code you see below
(if you can't read it, click the reset button on the right side of the image box)