(Optional - Name)                      

(Optional - Email Address)

Which procedure did you have?        Click arrow for choice. Open Gastric Bypass Lap Gastric Bypass Lap Band Realize Band None - Procedure was cancelled

What year was your surgery?             Click arrow for choice. 2007 2006 2005 2004 2003 2002 2001 2000 Before 2000

In what hospital was your surgery?  Click arrow for choice. Grandview Southview Kettering Sycamore Good Samaritan Miami Valley Greene Memorial - Xenia

What doctor did your surgery?          Click arrow for choice. Dr. Clarey Dr. Bruce Dr. Siddiqui

How many pounds did you lose?      Click arrow for choice. 0 - 50 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 175 200 225 250 275 300 300+        

If more than 300, how much?             

Have you maintained your weight loss?     Yes     No

Do you attend Support Group?    Yes     No

Where did you have your procedure done?       Click arrow for choice. Grandview Southview Kettering Sycamore Good Samaritan Miami Valley Greene Memorial - Xenia

Did you like your hospital room?    Yes        No

Comments about your room -

Did you like your floor nurses?       Yes        No

Comments about your floor nurses -

Did you have much pain after surgery?    Yes        No

If "Yes", was it controlled with the pain medicine they gave you?     Yes        No

Comments about your hospital stay -

How was your Operating Room (O.R.) experience?

Excellent           Good           Fair            Bad           I don't remember

How were the O.R. staff?

Excellent           Good           Fair           Bad           I don't remember

Comments about your O.R. experience or the staff -

Were the doctors kind and considerate at the hospital?                Yes        No

Were the doctors kind and considerate at the doctor's office?    Yes        No

Comments about the doctors (including Surgical Residents) 

Is the doctor's office staff kind and considerate?               Yes     No

Would you recommend the Dayton Bariatric Center?       Yes     No 

Would you recommend: (only check the hospital where you had your surgery)

Grandview Hospital?               Yes        No   

Southview Hospital                  Yes        No   

Good Samaritan Hospital       Yes         No   

Please add any comments or suggestions so we may improve our services for future patients.

Thank you!!

 Please close this page to return to the website.