Weight Loss Surgery Questionaire

Here are the Pre-Screening Questions to help you decide if WLS is right for you. Copy and past them to an email or word document and send them to Dr. John to start your weight loss journey :-)
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For Driver’s who are truly interested in Weight Loss Surgery? Call, email or Fax the below information to Dr John’s Trucker’s On Call Center. Dr John will talk to each driver personally. See Trucker’s ON Call Center contact information at the bottom.

1. Name:
2. Age:
3. Sex: M F
4. Height: 0'0" Weight:000 pounds BMI:
5. Employer:
6. Do you have Insurance?
7. If yes does it cover weight loss surgery?
8. Call back phone #:
9. Number of years obese:
10. List of diets tried including medically supervised attempts:
11. Medication list and dosage:
12. List of previous surgical procedures and year of the procedure:
13. Do you have any of the following, answer with yes or no:
    -High Blood Pressure
    -Diabetes
    -Sleep Apnea
    -Indigestion (GERDS) requiring medication or over the counter medication
    -Cholesterol elevations
    -Muscle or arthritis problems, Back pain/surgery
    -Lung problems or Pulmonary Hypertension, Heart Disease/Angina, heart failure, COPD
    -Previous Cancer Treatment, Gout
    -Metabolic Syndrome (Circle if you have HBP, Diabetes, Cholesterol, a BMI over 40)
    -Liver Disease. For example Hepatitis, Cirrhosis.
    -Female drivers only: Polycystic Ovaries, Menstrual Irregularities
14. Alcohol consumption:
    
15. Tobacco history:
    
16. Reason you are interested in weight loss surgery?
    

Dr John’s Trucker’s ON Call Center
Fax or call 8am- 5pm M-F EST
Phone: 865-862-8902
Fax: 865-558-9551
Email any time: jmcelligott@ohswest.com