Heartland Weight Loss Clinic - Online Assessment

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Boost Bariatrics

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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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NOT IN USE 05/25/22. 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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Do you suffer from 1 or more of these common health issues?* This field is required.Acid Reflux, High Blood Pressure, Sleep Apnea, Diabetes, Joint/Bone Issues, Depression

Yes

No

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What is your biggest challenge or question right now?* This field is required.

Can I afford it?

Is surgery right for me?

Will I keep the weight off?

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NOT IN USE 05/25/22: Which payment option describes you best?* This field is required.

Cash/Financing

Private Insurance

Medicare

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Which treatment are you considering?* This field is required.

Not Sure Yet

Gastric Bypass

Gastric Sleeve

Duodenal Switch

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Which payment option describes you best?* This field is required.

Self-Pay / Financing

Private Insurance

Medicare

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Where are you in your 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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NOT IN USE 05/25/22: 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 Email Course about your weight loss options from Heartland Weight Loss Clinic in Cape Girardeau, Missouri. 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. By providing your cell phone number you agree to receive calls and texts to that number from Heartland Weight Loss Clinic.

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