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Name: ______________________________Date: ___________________The following information will help us determine if you are a candidate for the ReShape? Dual Balloon procedure. If you check a box, it does not necessarily mean you should not have the procedure, it just means additional questions may be asked. Please check the box if you currently have or have experienced: Prior gastrointestinal surgeryPrior bariatric surgery Any inflammatory disease of the GI tract including esophagitis, ulcers, cancer or specific inflammation such as Crohn’s disease Upper gastrointestinal bleeding A stomach mass A hiatal hernia with severe reflux symptoms A structural problem in the esophagus Bleeding disordersLiver disorders such as cirrhosis Serious or uncontrolled psychiatric illness Alcoholism or drug addiction Unwilling to follow a medically-supervised diet and behavior modification program, with routine medical follow-up and nutrition coaching Taking prescribed daily aspirin, anti-inflammatory agents, or anticoagulants Unable or unwilling to take antacid medication for the duration of the balloon implant periodSerotonin syndrome while taking antidepressantsYou are currently pregnant or breast-feeding ................
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