Dignity Health Medical Group [Arizona]

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I am...

Male

Female

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Do you struggle to maintain a healthy weight using only diet and exercise?

Yes

No

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Do you suffer from any of these common health issues?Select all that apply. Then select "Next."

Heartburn / Acid Reflux

High Blood Pressure

Sleep Apnea

Diabetes

Joint/Bone Issues

Depression

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Hidden field: if heartburn is selected, pass in value of 1

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Hidden field: Pass in Heartburn if value is 1 from previous question

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Hidden: Convert Height to Total Inches

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Hidden: BMI Calculator

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What is your height and weight?* This field is required.Enter your height and weight below.

Weight (lbs)

Height (ft)

Height (in)

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What is your biggest challenge or question right now?* This field is required.Select one from below.

Can I afford it?

Is surgery right for me?

Will I keep the weight off long-term?

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Have you decided which treatment is right for you?Select one from below. If you are not sure yet, that is perfectly fine. Just select "Not Sure Yet"

Not Sure Yet

Gastric Sleeve

Gastric Bypass

Duodenal Switch

Medically Supervised Weight Loss Program

Gastric Balloon

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Where are you in your Weight Loss Surgery decision process?* This field is required.

Step 1. Researching

Step 2. Evaluating Treatments

Step 3. Choosing my Doctor

Step 4. Ready to Book a Consult

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Thanks! Where can we send your results?* This field is required.Enter your information below to receive your Personalized Results. You will also receive an Educational Email Course about your weight loss options from Dignity Health Medical Group [Arizona]🔒 We keep your information safe and private. This Assessment is not intended or implied to be a substitute for professional medical advice, diagnosis, or treatment.

First Name

Last Name

Email

Phone

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Email

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Phone

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First Name

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Last Name

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Date of Submission

Date