Am I a Candidate?

   

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Am I a Candidate for a weight loss procedure?
 All information you provide below is optional. By submitting your information, you agree that it will be governed by our Privacy Policy.

The form below will help you better understand if you probably meet the National Institutes of Health primary guidelines for weight loss surgery. It may also serve as a guide in speaking with a bariatric surgeon in your area.

 
*= REQUIRED FIELD
Are you male or female?*
 
What is your height?*
 
What is your approximate weight?*
 
What is your age range?*
 
Do you suffer from any of the following conditions?
Type 2 Diabetes
Heart Disease
Stroke
Restrictive Lung Disease
Sleep Apnea
Infertility
 High Blood Pressure
High Cholesterol
Congestive Heart Failure
Pickwickian Syndrome
Degenerative Arthritis
 
Have you tried losing weight with diets?* Yes  No  
 
Have you tried losing weight with over-the-counter or prescription drugs?* Yes  No  
 
Have you tried exercise programs to lose weight?* Yes  No  
 

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Northern Arizona Healthcare - 1200 N. Beaver St., Flagstaff, Ariz. 86001 - 928 779-3366
Flagstaff Medical Center - 1200 N. Beaver St., Flagstaff, Ariz. 86001 - 928 779-3366
Verde Valley Medical Center - 269 S. Candy Lane, Cottonwood, Ariz. 86326 - 928 639-6000
VVMC - Sedona Campus - 3700 W. Highway 89A, Sedona, Ariz., 86336 - 928 204-3000