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* 1. Name:

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* 2. The following medical condition might excude you as a candidate for surgery and should be discussed with your weight loss surgeon before scheduling your procedure:

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* 3. If you live more than 3 hours from Joplin, you are required to remain in town until your first post-op visit (usually around 1 week)

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* 4. Failure to submit your completed packet at least two weeks before your scheduled surgery date will likely result in postponement of your surgery to a later date.

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* 5. After the Mini-Gastric Bypass, the majority of patients will show significant improvement or even total resolution of all of the following medical conditions except:

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* 6. Part of the pre-op process requires making contact with at least 5 post-op MGB patients. Each patient must provide you with a contact letter.

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* 7. After MGB surgery you will lose weight because: (choose all that apply)

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* 8. If you are married, your spouse must write a letter supporting your decision to undergo the Mini-Gastric Bypass procedure.

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* 9. As part of your preparation for surgery, you are required to make contact with at least ____ of our post-op patients and write a short summary of what information you have learned from them regarding the Mini-Gastric Bypass. Contact can be in the form of direct contact (for example, meeting at seminars), contact via telephone or email, or in the form of a contact letter which some patients choose to write.

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* 10. Please match the following terms with their appropriate definition

  Gastric Ghrelin Restrictive component Body Mass Index Multivitamin
Small stomach pouch
Medical term for stomach
BMI
Daily for lifetime
Hunger Hormone

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* 11. Patients should keep copies of all of the information they collect for their packet to keep for their own record and should bring it with them to their pre-op clinic visit.

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