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Copyright 2009 Patrick Chiasson, MD & Stephen Burpee, MD
Minimally Invasive Surgery & Weight Loss Center
Patrick Chiasson, MD & Stephen Burpee, MD
BARIATRIC HEALTH OUTCOME SURVEY
Thank you. We value you as our patient.
Please press the "submit" button
to complete the survey and you will be
directed back to the home page.
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1. Last name:
2. First Initial:
3. Year of Birth:
4. My surgeon was:
5. Bariatric procedure performed:
6. Current weight:
7. What was your goal weight?
8. Are you happy with your achieved weight loss?
9. Please rate your current health status.
10. Please rate the current status of your original co-morbid conditions such as hypertension, diabetes, GERD, etc?
11. Are you continuing to experience any post-op issues such as nausea, vomiting or dumping syndrome?
***If you are experiencing any of the above issues, please contact our office or your primary care physician right away to schedule an appointment.12. Are you snacking?
13. Are you exercising?
14. Are you taking vitamins?
15. What medications are you taking?
16. Please rate your experience with our office and surgeons.
17. Would you refer a friend or family member to our practice?
Tucson, AZ
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