Feedback Form

This form is for patients who have had their weight loss operation over 12 months to provide Feedback on their experience with the operation and the clinic. 

This feedback is critical for us to improve our performance and understand the real impact of the surgery over time. 

The form is anonymous unless you include your name in the general comments section.

The Operation

a. ?
Gastric Band Sleeve Gastrectomy Gastric Bypass Endobarrier SIPS Surgery Intra-gastric Balloon
b. ?
None Gastric Band Sleeve Gastrectomy Stomach Stapling Other
c. Satisfaction ratings:
?
Exceeded expectations Met expectations Did not meet expectations
?
Very positive A little positive Neutral A little negative Very negative
?
I can eat anything I can eat most things There are many things I cannot eat I cannot eat most things
?
Have this weight loss operation again Choose a different weight loss operation Not have any weight loss operation

 

The Clinic (Rating scale 1 – 10, click on the box or circle. Higher is better)

a. Clinic staff
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
b. Your surgeon
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
1 2 3 4 5 6 7 8 9 10
c.
Definitely Probably Not Sure Probably Not Definitely Not

 

1 2 3 4 5 6 7 8 9 10

 

Yes No