FARIDA BOUNOUA, M.D
Diplomat of the American Board of Surgery
Minimally Invasive and Bariatric Surgery
2323 De La Vina Street, # 207
Santa Barbara, CA, 93105
Ph: 805-879-4011
Fax: 805-879-4021
Lap Band Preop Test
Name:
1)How much water should I drink Daily
a-8 ounces or 1 glass
b-As many 4-6 ounce glasses an hour, as I can ( more than 3 at least)
c-1 liter of soda
2) Overeating can result in:
a-Feeling satisfied with no consequences
b-Vomiting, pouch expansion, ruptured stomach or weight gain
c-Nothing, since my stomach is a small pouch
3) I should call the dietician if I:
a) Have problems tolerating my protein drink
b)Didn't like my protein drink so i stopped
c) Am suffering from gas, bloating, diarrhea, constipation or nausea
d)Want to be creative in the kitchen, but don t have any ideas
e) all of the above
4) Post-operatively, I am limiting to lifting
a. 60 pounds
b. 20pounds
c. 10pounds
d. no limit
5)I need to try solid food
a. One week before my adjustement
b. Never... after surgery, I'll be on liquids for life
c.On my way home from the hospital
6)I should go to the emergency room or call Dr Bounoua if
a.chest pain
b.Shortness of breath
c.postopertaive site bleeding, or rectal bleeding
d. unable to keep liquid down, vomiting
e.all of the above
FARIDA BOUNOUA, M.D
Diplomat of the American Board of Surgery
Minimally Invasive and Bariatric Surgery
2323 De La Vina Street, # 207
Santa Barbara, CA, 93105
Ph: 805-879-4011
Fax: 805-879-4021
Lap Band Preop Test
Name:
7) What should you bring to the hospital with you
a.ID and insurance card
b.Signed durable power of attorney for health care or advance directive if you have one
c.Cell phone turned off, if available
d.All of the above
8)I should contact the clinic or go to the emergency room if I develop
a. Abdominal pain
b.Fever
c.Shortness of breath or chest pain
d.Persistant Diarrhea or constipation
e.Excessive heartburn, nausea, or vomiting
f.All of the above
True or False
9.A clear liquid diet consists of clear broths, clear juices, popsicles, jello, clear tea and does not include food:
True
False
10.The day before the surgery I should have a regular breakfast, clear liquids, the rest of the day, Fleets
Phospha-soda at noon, and then have nothing after midnight the night before surgery.
True
False
11.I can eat and drink at the same time:
True
False
12.When I think about a meal or snack, I should think about "Protein first":
True
False
13.After surgery, I can use a straw:
True
False
FARIDA BOUNOUA, M.D
Diplomat of the American Board of Surgery
Minimally Invasive and Bariatric Surgery
2323 De La Vina Street, # 207
Santa Barbara, CA, 93105
Ph: 805-879-4011
Fax: 805-879-4021
Lap Band Preop Test
Name:
14.I can never eat fruits or vegetables again: True
False
15.I can use Benifiber mixed with water to help me feel full and have regular bowel movements:
True
False
16. I should try my vitamins before the surgery and stop one week prior:
True
False
17. After surgery I don't need to do any type of activity because I am going to be eating so little, I will lose
the weight without exercise:
True
False
18. I should take protein drinks after the surgery, that will help my energy level:
True
False
19. After a Lap adjustable band placement there is a 2-3% risk of band erosion,a 5% risk of band slippage
True
False
20. After a lap band there is a 0.6 risk of death
___ Yes ___ No
True
False
I was given the opportunity to ask questions and was given a response to all my questions and concerns.
I certify that I took this test myself, without any help in answering the questions, during the exam.
Signature:____________________________________ Date:_____________________
Examiner:____________________________________
Incorrect answers reviewed and clarified with the patient.
______________________________________________