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		<title>Sample Surgery Agenda Cancun</title>
		<link>http://www.obesitysolutions.us/sample-surgery-agenda-cancun.htm</link>
		<comments>http://www.obesitysolutions.us/sample-surgery-agenda-cancun.htm#comments</comments>
		<pubDate>Thu, 20 Oct 2011 05:41:47 +0000</pubDate>
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		<description><![CDATA[Video Gallery Content on this page requires a newer version of Adobe Flash Player. At Obesity Solutions and International Patient Facilitators in Cancun and Tijuana Mexico, we know that surgery can be a stressful event. That is the reason why we have very delicately designed a surgical experience that is organized and step oriented. When you know what’s to come, you can better envision your surgery plan and the stress level is much more bearable. Our goal is to provide patients with the information they require to make a well informed and educated decision to have their surgery organized by us. We run the most transparent program in all of Mexico. We have broken this down into two different agendas: Tijuana and Cancun DAY ONE: ARRIVAL CANCUN INTERNATIONAL AIRPORT When arriving in Cancun, please collect your luggage and go outside where you will be met by our team and chauffeured to your accommodations to get settled in and have a nice swim in the Caribbean Sea. This is your time to see a bit of Cancun and to enjoy a truly marvelous destination DAY TWO: PRE.OP WORK AND SURGERY DAY CANCUN you will be met by our chauffeurs and our [...]]]></description>
			<content:encoded><![CDATA[<h3>Video Gallery</h3>
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At Obesity Solutions and International Patient Facilitators in Cancun and Tijuana Mexico, we know that surgery can be a stressful event. That is the reason why we have very delicately designed a surgical experience that is organized and step oriented. When you know what’s to come, you can better envision your surgery plan and the stress level is much more bearable. Our goal is to provide patients with the information they require to make a well informed and educated decision to have their surgery organized by us. We run the most transparent program in all of Mexico.</p>
<p><b>We have broken this down into two different agendas: Tijuana and Cancun</b></p>
<h2>DAY ONE: ARRIVAL CANCUN INTERNATIONAL AIRPORT</h2>
<p>When arriving in Cancun, please collect your luggage and go outside where you will be met by our team and chauffeured to your accommodations to get settled in and have a nice swim in the Caribbean Sea. This is your time to see a bit of Cancun and to enjoy a truly marvelous destination</p>
<h2>DAY TWO: PRE.OP WORK AND SURGERY DAY CANCUN</h2>
<ul>
<li>you will be met by our chauffeurs and our team and taken to the facility of your choice (either the Victoria, Amerimed or Galenia Hospital) where you will have your labwork, EKG and chest x. ray performed.</li>
<li>You will have a full consultation with your surgical team and all last minute questions will be answered.</li>
<li>You will fill out all your consent forms, make final payment and get prepped for surgery.</li>
<li>Patients having Bypass or Mini Gastric Bypass and patients who are considered High Risk Patients will be having their surgery in either the Amerimed or Galenia Hospital</li>
<li>Patients having surgery in the Victoria surgery center will spend one to two nights at the surgery center after their surgery is performed.</li>
<li>Your procedure is performed using a laparoscopic approach and surgery time will vary for each individual.</li>
<li>Patients will be up and walking only a few hours after surgery.</li>
<li>Family members are welcome to join them and are welcome to spend the night in their room with them.</li>
<li>Patients have free wifi and Cable TV</li>
</ul>
<h2>DAY TWO: REST AND RECOVERY TIJUANA</h2>
<p>This day is dedicated for rest and relaxation and recovery for patients having the Vertical Sleeve Gastrectomy, Mini Gastric Bypass and Full Gastric Bypass procedures. Patients are showered and are expected to get up and walk every hour or two for 15 minutes.<br />
Lap Band and Gastric Plication Patients are released this day after spending 24 hours with us. They will meet with their surgery team and have a discussion about nutrition and how to best achieve the desired results with their new Weight Loss Surgery Tool. They will be chauffeured back to their accommodations where they will spend an additional night before returning to the US and to the airport for their journey home.</p>
<h2>DAY THREE: RECOVERY AND RETURN TO THE US /// OTHER PATIENTS DISCHARGED</h2>
<p>This day is the day that lap band and gastric plication patients will return to the Airport to catch their flight back home. They will be chauffeured by our transportation company back to Cancun International Airport.</p>
<p>This day is the day that our Gastric Sleeve, Mini Gastric Bypass and Full Gastric Bypass patients are released after having their post op testing performed and after meeting with their bariatric surgery team once again to discuss their new tool and their new lifestyle. They will be chauffeured to their accommodations where they will spend an additional night before returning home to the US.</p>
<p>We require that all patients commit to a follow up with their general practitioner back home six to eight weeks post procedure.</p>
]]></content:encoded>
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		<title>Intra Gastric Balloon Procedure in Cancun and Tijuana Mexico</title>
		<link>http://www.obesitysolutions.us/intra-gastric-balloon-procedure-in-cancun-and-tijuana-mexico.htm</link>
		<comments>http://www.obesitysolutions.us/intra-gastric-balloon-procedure-in-cancun-and-tijuana-mexico.htm#comments</comments>
		<pubDate>Thu, 20 Oct 2011 04:38:36 +0000</pubDate>
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		<description><![CDATA[The Intra Gastric Balloon is a non-surgical very minimal invasive procedure that involves the placement of an empty silicone balloon into the stomach endoscopically and then it is filled with a blue tinted saline solution. Patients are under sedation during this procedure. The entire procedure takes approximately 15 minutes and patients are able to return to their accommodations very shortly afterwards. The adjustment period is approximately 2 to 3 days. The Intra Gastric Balloon is a great way to lose weight and it is a completely reversible procedure. A normal weight loss in a 6 month period is anywhere from 30 &#8211; 40 lbs Intra Gastric Balloon Procedure in Cancun, Tijuana, Mexico: How does it work? The Intra Gastric Balloon System is a non-surgical, non-pharmaceutical aid in the treatment of obesity. Together with a nutritional plan and behavior modification program, it can help patients reach their weight loss goals. The Intra Gastric Balloon System is made of a gentle, expandable balloon, a placement tube and a filling station so our bariatric surgeon can orally insert the weight loss aid. Once inserted in the stomach, the empty balloon is filled with sterile, blue, saline solution. When full, the balloon is too [...]]]></description>
			<content:encoded><![CDATA[<p>The Intra Gastric Balloon is a non-surgical very minimal invasive procedure that involves the placement of an empty silicone balloon into the stomach endoscopically and then it is filled with a blue tinted saline solution.  Patients are under sedation during this procedure.   The entire procedure takes approximately 15 minutes and patients are able to return to their accommodations very shortly afterwards.</p>
<p>The adjustment period is approximately 2 to 3 days.  The Intra Gastric Balloon is a great way to lose weight and it is a completely reversible procedure.  A normal weight loss in a 6 month period is anywhere from 30 &#8211; 40 lbs</p>
<h2>Intra Gastric Balloon Procedure in Cancun, Tijuana, Mexico: How does it work?</h2>
<p>The Intra Gastric Balloon System is a non-surgical, non-pharmaceutical aid in the treatment of obesity. Together with a nutritional plan and behavior modification program, it can help patients reach their weight loss goals.</p>
<p>The Intra Gastric Balloon System is made of a gentle, expandable balloon, a placement tube and a filling station so our bariatric surgeon can orally insert the weight loss aid.</p>
<p>Once inserted in the stomach, the empty balloon is filled with sterile, blue, saline solution. When full, the balloon is too large to pass into the bowel and will now float freely in the stomach offering a good restriction on the amount of food a patient can consume post procedure.</p>
<h2>Intra Gastric Balloon: What are its advantages?</h2>
<p>The Intra Gastric Balloon currently can be placed for six months. Longer periods of use are not suggested. With time the acidic content of the stomach will weaken and break down the balloon material and cause the balloon to deflate inside of the stomach. If your physician recommends a use of the gastric balloon for longer than six months, it is necessary that the balloon be replaced with a new one when the six-month interval has been met.</p>
<h2>Intra Gastric Balloon Procedure in Cancun and Tijuana, Mexico</h2>
<p><b>In short, the main features of gastric balloon procedure can be summarized as:</b><br />
It is important for patients to understand that the Intra Gastric Balloon Procedure is a tool to weight reduction and must be used together with a prescribed diet and behavior modification program. The amount of weight you lose will depend on how closely you follow your diet. How long you maintain your weight loss will depend on how completely you adopt long-term lifestyle changes involving eating behavior and exercise.</p>
<p>More than likely the presence of the gastric balloon in the stomach will cause nausea or vomiting for a few days after inserted. Your Doctor will prescribe medication to relieve these feelings.</p>
<p>There also exists the possibility that you will lose only a small amount of weight or lose no weight at all while using the balloon. As stated earlier, your commitment and desire to  change and lose weight is a pivotal factor in the success of the intra gastric balloon .<br />
<img src="http://www.obesitysolutions.us/wp-content/uploads/2011/10/D5CA1.jpeg" alt="" title="" width="241" height="240"  style="border:2px solid #000; margin:5px;" /></p>
<p>To discuss your specific situation in confidence, please call us toll free from the U.S. or Canada at: <b><u>1 800 210 5124</u></b></p>
]]></content:encoded>
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		<title>Sample Surgery Agenda Tijuana</title>
		<link>http://www.obesitysolutions.us/sample-surgery-agenda-tijuana.htm</link>
		<comments>http://www.obesitysolutions.us/sample-surgery-agenda-tijuana.htm#comments</comments>
		<pubDate>Tue, 18 Oct 2011 11:18:30 +0000</pubDate>
		<dc:creator>admin</dc:creator>
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		<guid isPermaLink="false">http://www.obesitysolutions.us/?p=922</guid>
		<description><![CDATA[Video Gallery Content on this page requires a newer version of Adobe Flash Player. At Obesity Solutions and International Patient Facilitators in Cancun and Tijuana Mexico, we know that surgery can be a stressful event. That is the reason why we have very delicately designed a surgical experience that is organized and step oriented. When you know what&#8217;s to come, you can better envision your surgery plan and the stress level is much more bearable. Our goal is to provide patients with the information they require to make a well informed and educated decision to have their surgery organized by us. We run the most transparent program in all of Mexico. We have broken this down into two different agendas: Tijuana and Cancun DAY ONE: ARRIVAL AND SURGERY DAY TIJUANA Tijuana/ Upon arrival in SanDiego, you will be met by our chauffeurs and taken across the border and directly to the Obesity Goodbye Center where you will have your labwork, EKG and chest x. ray performed. You will have a full consultation with your surgical team and all last minute questions will be answered. You will fill out all your consent forms, make final payment and get prepped for surgery. [...]]]></description>
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<h3>Video Gallery</h3>
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<p>At Obesity Solutions and International Patient Facilitators in Cancun and Tijuana Mexico, we know that surgery can be a stressful event. That is the reason why we have very delicately designed a surgical experience that is organized and step oriented. When you know what&#8217;s to come, you can better envision your surgery plan and the stress level is much more bearable. Our goal is to provide patients with the information they require to make a well informed and educated decision to have their surgery organized by us. We run the most transparent program in all of Mexico.</p>
<p><strong>We have broken this down into two different agendas: Tijuana and Cancun</strong></p>
<h2>DAY ONE: ARRIVAL AND SURGERY DAY TIJUANA</h2>
<ul>
<li>Tijuana/ Upon arrival in SanDiego, you will be met by our chauffeurs and taken across the border and directly to the Obesity Goodbye Center where you will have your labwork, EKG and chest x. ray performed.</li>
<li>You will have a full consultation with your surgical team and all last minute questions will be answered.</li>
<li>You will fill out all your consent forms, make final payment and get prepped for surgery.</li>
<li>Patients having Bypass or Mini Gastric Bypass and patients who are considered High Risk Patients will be transferred to the INT Hospital where they will have their surgery performed.</li>
<li>Patients having surgery in our surgery center will spend one to two nights at the surgery center after their surgery is performed.</li>
<li>Your procedure is performed using a laparoscopic approach and surgery time will vary for each individual.</li>
<li>Patients will be up and walking only a few hours after surgery.</li>
<li>Family members are welcome to join them and are welcome to spend the night in their room with them.</li>
<li>Patients have free wifi and Direct TV</li>
</ul>
<h2>DAY TWO: REST AND RECOVERY TIJUANA</h2>
<p>This day is dedicated for rest and relaxation and recovery for patients having the Vertical Sleeve Gastrectomy, Mini Gastric Bypass and Full Gastric Bypass procedures. Patients are showered and are expected to get up and walk every hour or two for 15 minutes.</p>
<p>Lap Band and Gastric Plication Patients are released this day after spending 24 hours with us. They will meet with their surgery team and have a discussion about nutrition and how to best achieve the desired results with their new Weight Loss Surgery Tool. They will be chauffeured to a 5 star hotel where they will spend an additional night before returning to the US and to the airport for their journey home.</p>
<h3>DAY THREE: RECOVERY AND RETURN TO THE US /// OTHER PATIENTS DISCHARGED</h3>
<p>This day is the day that lap band and gastric plication patients will return to the US to catch their flight back home. They will be chauffeured by our transportation company.<br />
This day is the day that our Gastric Sleeve, Mini Gastric Bypass and Full Gastric Bypass patients are released after having their post op testing performed and after meeting with their bariatric surgery team once again to discuss their new tool and their new lifestyle. They will be chauffeured to their 5 star hotel where they will spend an additional night before returning home to the US.</p>
<p>We require that all patients commit to a follow up with their general practitioner back home six to eight weeks post procedure.</p>
]]></content:encoded>
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		<title>Gastric Plication Surgery</title>
		<link>http://www.obesitysolutions.us/gastric-plication-surgery.htm</link>
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		<pubDate>Thu, 18 Nov 2010 06:52:07 +0000</pubDate>
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		<description><![CDATA[GPS Procedure (Gastric Plication Surgery) in Mexico Dr.Verboonen is proud to be one of the first surgeons in Mexico to offer a new weight loss procedure called GPS (Gastric Plication Surgery). Gastric Plication Surgery is currently the lowest cost weight loss procedure available! The GPS Procedure involves reducing the stomach volume by imbricating and stitching (plicating) the stomach wall reducing it to the size of a narrow tube. This surgery emulates the sleeve gastrectomy but doesn&#8217;t involve any cutting or stapling of the stomach. Your natural stomach remains; it is simply imbricated on itself so that the stomach volume is reduced. The GPS Procedure is now the lowest cost weight loss operation available because it doesn&#8217;t require expensive medical devices. Early results show GPS weight loss equivalent to the sleeve gastrectomy which is similar to the gastric bypass. GPS patients say they feel full on small amounts of food. The GPS procedure has no malabsorption like gastric bypass and no need for a port or adjustments like gastric banding. The GPS procedure is ideal for patients that desire a weight loss procedure that is lower cost and does not require a port or adjustments. We call this the GPS procedure [...]]]></description>
			<content:encoded><![CDATA[<h2>GPS Procedure (Gastric Plication Surgery) in Mexico</h2>
<p>Dr.Verboonen is proud to be one of the first surgeons in Mexico to offer a new weight loss procedure called GPS (Gastric Plication Surgery). Gastric Plication Surgery is currently the lowest cost weight loss procedure available!</p>
<p>The GPS Procedure involves reducing the stomach volume by imbricating and stitching (plicating) the stomach wall reducing it to the size of a narrow tube. This surgery emulates the sleeve gastrectomy but doesn&#8217;t involve any cutting or stapling of the stomach. Your natural stomach remains; it is simply imbricated on itself so that the stomach volume is reduced.<br />
<img src="http://www.obesitysolutions.us/wp-content/uploads/2010/11/insert_gps_surgery.jpg" alt="" title="insert_gps_surgery" align="left"  style="margin:10px 10px 0 0;border:1px solid #b99b68"/>The GPS Procedure is now the lowest cost weight loss operation available because it doesn&#8217;t require expensive medical devices. Early results show GPS weight loss equivalent to the sleeve gastrectomy which is similar to the gastric bypass. GPS patients say they feel full on small amounts of food. The GPS procedure has no malabsorption like gastric bypass and no need for a port or adjustments like gastric banding.</p>
<p>The GPS procedure is ideal for patients that desire a weight loss procedure that is lower cost and does not require a port or adjustments. We call this the GPS procedure because we have adapted the procedure to our cosmetic techniques and the routine repair of hiatal hernias. Other names for the procedure include: greater curvature plication, gastric imbrication, total vertical sleeve plication, etc. Our GPS patients describe feeling full on small meals and their weight loss is excellent.</p>
<h5>Surgery of Obesity and Metabolic Disorders (IFSO) held in September 2010 (“Gastric Plication: A New Option in Obesity Surgery”) demonstrate lower risk of complication and weight loss results faster and more intense than gastric banding , comparable to weight loss rates observed for gastric bypass, i.e. 70%+ excess weight loss 12 months post-procedure.</h5>
<ul>
<li>A less invasive evolution of the gastric sleeve procedure, plication is an ambulatory procedure – no surgical drains, only 2 nights total hospital stay!</li>
<li>No loss of stomach tissue &#8211; the &#8216;sleeve&#8217; is created by suturing rather than removal (preserving nutrient absorption capability)Diagram</li>
<li>No devices &#8211; no staples, no bands, no fills</li>
<li>Reduced risk of early or late complications</li>
<li>No complication from leaks or bleeding at the staple line (as compared to gastric sleeve)</li>
<li>Does not impair patient dietary habits</li>
<li>Early data (patients at 6-12 months post procedure) indicate resultant weight loss is comparable to gastric bypass</li>
<p><img src="http://www.obesitysolutions.us/wp-content/uploads/2010/11/img_GS-Plication.jpg" alt="" title="img_GS-Plication" align="lift"  style="margin:0;border:1px solid #b99b68"/>
</ul>
<div class="clear"></div>
<p><strong>Surgical Progression of the stomach during gastric plication:</strong><br />
The stomach is restricted into a sleeve-like shape through the use of non-absorbable surgical suturing.</p>
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		<description><![CDATA[YOUR SAFETY DEPENDS ON THE ACCURACY OF THE INFORMATION PROVIDED. Fill the forms and then click SUBMIT. If you do not get confirmation your forms were not sent. Procedure: Patient facilitator name: *Name: Sex *Age: Date of Birth: &#160; &#160; &#160; &#160; &#160; *E-mail: *Height: *Weight: *BMI: Select 4' 5" (135 cm) or below 4' 6" (137 cm) 4' 7" (140 cm) 4' 8" (142 cm) 4' 9" (145 cm) 4' 10" (147 cm) 4' 11" (150 cm) 5' 0" (152 cm) 5' 1" (155 cm) 5' 2" (157 cm) 5' 3" (160 cm) 5' 4" (162 cm) 5' 5" (165 cm) 5' 6" (167 cm) 5' 7" (170 cm) 5' 8" (173 cm) 5' 9" (175 cm) 5' 10" (178 cm) 5' 11" (180 cm) 6' 0" (183 cm) 6' 1" (185 cm) 6' 2" (188 cm) 6' 3" (190 cm) 6' 4" (193 cm) 6' 5" (196 cm) 6' 6" (198 cm) 6' 7" (201 cm) 6' 8" (203 cm) 6' 9" (206 cm) 6' 10" (208 cm) 6' 11" (211 cm) 7' 0" (213 cm) or above Address: City State Zip&#160; *Telephone: &#160;Cell Phone: Maximum Weight: When? Date of surgery: *List all Medicine Allergies: *Name of person [...]]]></description>
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			<p><strong>YOUR SAFETY DEPENDS ON THE ACCURACY OF THE INFORMATION PROVIDED.</strong><br /> 
              Fill the forms and then click SUBMIT. If you do not get confirmation your forms were not sent.</p></td> 
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              <tr> 
                <td>Procedure:</td> 
                <td><input name="PF" id="PF" size="25" type="text" /></td> 
                <td>Patient facilitator name:</td> 
                <td><input name="PF1" id="PF" size="25" type="text" /></td> 
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            <td ><table border="0" cellpadding="0" cellspacing="3"> 
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                <td width="333"><span class="style1">*</span>Name:</td> 
                <td width="62">Sex</td> 
                <td width="66"><span class="style1">*</span>Age:</td> 
                <td colspan="2">Date of
                      Birth:</td> 
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                <td><input name="name" id="name" size="40" type="text" class="requ" /></td> 
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                <td width="53">&nbsp;</td> 
                <td width="56">&nbsp;</td> 
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                <td><span class="style1">*</span>E-mail:</td> 
                <td><span class="style1">*</span>Height:</td> 
                <td><span class="style1">*</span>Weight:</td> 
                <td colspan="2"><span class="style1">*</span>BMI:</td> 
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              <tr> 
                <td><input name="email" type="text" class="requ"  size="40" /></td> 
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<option value="4' 6&quot; (137 cm)">4' 6" (137 cm)</option>
<option value="4' 7&quot; (140 cm)">4' 7" (140 cm)</option>
<option value="4' 8&quot; (142 cm)">4' 8" (142 cm)</option>
<option value="4' 9&quot; (145 cm)">4' 9" (145 cm)</option>
<option value="4' 10&quot; (147 cm)">4' 10" (147 cm)</option>
<option value="4' 11&quot; (150 cm)">4' 11" (150 cm)</option>
<option value="5'  0&quot; (152 cm)">5'  0" (152 cm)</option>
<option value="5' 1&quot; (155 cm)">5' 1" (155 cm)</option>
<option value="5' 2&quot; (157 cm)">5' 2" (157 cm)</option>
<option value="5' 3&quot; (160 cm)">5' 3" (160 cm)</option>
<option value="5' 4&quot; (162 cm)">5' 4" (162 cm)</option>
<option value="5' 5&quot; (165 cm)">5' 5" (165 cm)</option>
<option value="5' 6&quot; (167 cm)">5' 6" (167 cm)</option>
<option value="5' 7&quot; (170 cm)">5' 7" (170 cm)</option>
<option value="5' 8&quot; (173 cm)">5' 8" (173 cm)</option>
<option value="5' 9&quot; (175 cm)">5' 9" (175 cm)</option>
<option value="5' 10&quot; (178 cm)">5' 10" (178 cm)</option>
<option value="5' 11&quot; (180 cm)">5' 11" (180 cm)</option>
<option value="6' 0&quot; (183 cm)">6' 0" (183 cm)</option>
<option value="6' 1&quot; (185 cm)">6' 1" (185 cm)</option>
<option value="6' 2&quot; (188 cm)">6' 2" (188 cm)</option>
<option value="6' 3&quot; (190 cm)">6' 3" (190 cm)</option>
<option value="6' 4&quot; (193 cm)">6' 4" (193 cm)</option>
<option value="6' 5&quot; (196 cm)">6' 5" (196 cm)</option>
<option value="6' 6&quot; (198 cm)">6' 6" (198 cm)</option>
<option value="6' 7&quot; (201 cm)">6' 7" (201 cm)</option>
<option value="6' 8&quot; (203 cm)">6' 8" (203 cm)</option>
<option value="6' 9&quot; (206 cm)">6' 9" (206 cm)</option>
<option value="6' 10&quot; (208 cm)">6' 10" (208 cm)</option>
<option value="6' 11&quot; (211 cm)">6' 11" (211 cm)</option>
<option value="7' 0&quot; (213 cm) or above">7' 0" (213 cm) or above</option>
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                <td><input name="weight" type="text" class="requ" id="weight" size="5" /></td> 
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                <td width="300">Address:</td> 
                <td width="167">City</td> 
                <td width="46"> State </td> 
                <td width="50">Zip&nbsp;</td> 
                </tr> 
              <tr> 
                <td><input name="address" id="address" size="40" type="text" /></td> 
                <td><input name="city" id="city" size="20" type="text" /></td> 
                <td><input name="state" id="state" size="3" type="text" /></td> 
                <td><input name="zip" id="zip" size="5" type="text" /></td> 
                </tr> 
              <tr> 
                <td><span class="style1">*</span>Telephone: 
                  <input name="telhome" type="text" class="requ" id="telhome" size="20" /></td> 
                <td colspan="3">&nbsp;Cell Phone:
                  <input name="telcel" id="telcel" size="20" type="text" /></td> 
                </tr> 
            </table></td> 
          </tr> 
          <tr> 
            <td ><table width="100%" border="0" cellspacing="3" cellpadding="0"> 
              <tr> 
                <td width="108">Maximum
                      Weight:</td> 
                <td width="47"><input name="maxweight" id="maxweight" size="5" type="text" /></td> 
                <td width="45" align="right">When?</td> 
                <td width="118"><input name="maxweightwhen" id="maxweightwhen" size="10" type="text" /></td> 
                <td width="103" align="right">Date of
                      surgery:</td> 
                <td width="146"><input name="date_surgery" id="date_surgery" size="15" type="text" /></td> 
              </tr> 
              <tr> 
                <td colspan="6"><span class="style1">*</span>List <u>all</u> Medicine Allergies:
                  <input name="medicineallergies" type="text" class="requ" id="medicineallergies" size="50" /></td> 
                </tr> 
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            <td ><table width="100%" border="0" cellspacing="3" cellpadding="0"> 
              <tr> 
                <td width="55%"><span class="style1">*</span>Name of
                          person to contact 
(in case of emergency): </td> 
                <td width="45%"><span class="style1">*</span>Emergency 
Phone #:</td> 
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                <td><input name="emergencynamecontact" type="text" class="requ" id="namecontactemergency" size="40" /></td> 
                <td><input name="emergencytel" type="text" class="requ" id="telemergency" size="20" /></td>
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            <td ><table border="0" cellspacing="3" cellpadding="0"> 
           
              <tr> 
                <td width="334"><span class="style1">*</span>Any Medical/physical problems (i.e., sleep apnea,
                      high blood pressure, 
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                <td width="58" align="left"><input name="Meidical_Physical_Problems" type="radio" class="radio" id="Meidical_Physical_Problems" value="yes" /> 
Yes</td> 
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                <td align="right">&nbsp;</td> 
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                <td align="right">&nbsp;</td> 
                <td colspan="3" align="left"><input name="medicalphysicalproblems" id="medicalphysicalproblems" size="30" type="text" /></td> 
                </tr> 
              <tr> 
                <td colspan="4" align="center" height="15"></td> 
                </tr> 
              <tr> 
                <td align="left">Are
                      you currently taking any medications or herbal supplements?</td> 
                <td align="left"><input name="taking_medications_supplents" value="yes"  type="radio" /> 
Yes</td> 
                <td align="center"><input name="taking_medications_supplents" value="no"  type="radio" /> 
No</td> 
                <td align="center"><input name="taking_medications_supplents" value="do not know"  type="radio" /> 
Do Not Know</td> 
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              <tr> 
                <td align="right">&nbsp;</td> 
                <td colspan="3" align="left">If Yes,
                      please list the name, dosage and reason for this medicine):</td> 
              </tr> 
              <tr> 
                <td align="right">&nbsp;</td> 
                <td colspan="3" align="left"><input name="medications_herbalsupplements" id="medicationsherbalsupplements" size="30" type="text" /></td> 
              </tr> 
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                 <td colspan="4" align="center" height="15"></td> 
              </tr> 
              <tr> 
                <td align="left">Is
                      there any history in your family of diabetes, cancer and/or hypertension?</td> 
                <td align="left"><input name="history_diabetes_cancer_hypertension" value="yes"  type="radio" /> 
Yes</td> 
                <td align="center"><input name="history_diabetes_cancer_hypertension" value="no"  type="radio" /> 
No</td> 
                <td align="center"><input name="history_diabetes_cancer_hypertension" value="do not know"  type="radio" /> 
Do Not Know</td> 
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              <tr> 
                <td align="right">&nbsp;</td> 
                <td colspan="3" align="left">If Yes,
                      please indicate which ones:</td> 
              </tr> 
              <tr> 
                <td align="right">&nbsp;</td> 
                <td colspan="3" align="left"><input name="history_family_diabetes_cancer_hypertension" id="history_family_diabetes_cancer_hypertension" size="30" type="text" /></td> 
                </tr> 
              <tr> 
                <td colspan="4" align="center" height="15"></td> 
              </tr> 
              <tr> 
                <td align="left">Any &nbsp;surgeries (i.e., gallbladder,
                      appendix, hernia, heart, etc.)?</td> 
                <td align="left"><input name="surgeries"  type="radio" value="yes" /> 
Yes</td> 
                <td align="center"><input name="surgeries" value="no" type="radio" /> 
No</td> 
                <td align="center"><input name="surgeries" value="do not know" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left">If Yes, please list:</td> 
                </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left"><input name="surgeries_list" id="surgeries_list" size="30" type="text" /></td> 
                </tr> 
              <tr> 
                <td colspan="4" align="center" height="15"></td> 
              </tr> 
              <tr> 
                <td align="left">Do
                      you have any adverse reaction to anesthesia? </td> 
                <td align="left"><input name="reaction_anestesia" value="yes" type="radio" /> 
Yes</td> 
                <td align="center"><input name="reaction_anestesia" value="no" i type="radio" /> 
No</td> 
                <td align="center"><input name="reaction_anestesia" value="do not know"  type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left">If Yes, please indicate the
                      reaction:</td> 
                </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left"><input name="anesthesia_reactions" id="anesthesia_reactions" size="30" type="text" /></td> 
                </tr> 
              <tr> 
                <td colspan="4" align="center" height="15"></td> 
                </tr> 
              <tr> 
                <td align="left">Do
                      you have dentures, dental implants, or caps? </td> 
                <td align="left"><input name="dentures_implants_caps" value="yes" type="radio" /> 
Yes</td> 
                <td align="center"><input name="dentures_implants_caps" value="no" type="radio" /> 
No</td> 
                <td align="center"><input name="dentures_implants_caps" value="do not know" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left">If Yes, please indicate where:</td> 
              </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left"><input name="dental_implants" id="dental_implants" size="30" type="text" /></td> 
              </tr> 
              <tr> 
                <td colspan="4" align="center" height="15"></td> 
              </tr> 
              <tr> 
                <td align="left">Do
                      you have any children?</td> 
                <td align="left"><input name="have_children" value="yes"  type="radio" /> 
Yes</td> 
                <td align="center"><input name="have_children" value="no"  type="radio" /> 
No</td> 
                <td align="center">&nbsp;</td> 
              </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left">If Yes, how many? 
                  <input name="how_many_children" id="how_many_children" size="5" type="text" /></td> 
              </tr> 
              <tr> 
                 <td colspan="4" align="center" height="15"></td> 
              </tr> 
              <tr> 
                <td align="left">Do
                      you have heavy periods? </td> 
                <td align="left"><input name="heavy_periods" value="yes" type="radio" /> 
Yes</td> 
                <td align="center"><input name="heavy_periods" value="no" type="radio" /> 
No</td> 
                <td align="center"><input name="heavy_periods" value="no"  type="radio" /> 
                  Do not have periods</td> 
              </tr> 
              <tr> 
                <td colspan="4" align="center" height="15"></td> 
              </tr> 
              <tr> 
                <td align="left">Do
                      you smoke? </td> 
                <td align="left"><input name="smoke" value="yes" type="radio" /> 
Yes</td> 
                <td align="center"><input name="smoke" value="no"  type="radio" /> 
No</td> 
                <td align="left">&nbsp;</td> 
              </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left">If Yes, how many cigarettes a day?
                  <input name="how_many_cigars" id="cigars" size="5" type="text" /></td> 
              </tr> 
              <tr> 
                 <td colspan="4" align="center" height="15"></td> 
                </tr> 
              <tr> 
                <td align="left">Do
                      you drink?&nbsp;</td> 
                <td align="left"><input name="drink" value="yes"  type="radio" /> 
Yes</td> 
                <td align="center"><input name="drink" value="no"  type="radio" /> 
No</td> 
                <td align="left">&nbsp;</td> 
              </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left">If Yes, how many? 
                  <input name="how_many_drinks" id="drinks" size="5" type="text" /></td> 
              </tr> 
              <tr> 
                <td colspan="4" align="center" height="15"></td> 
              </tr> 
              <tr> 
                <td align="left">Do
                      you do drugs? </td> 
                <td align="left"><input name="drugs" value="yes" type="radio" /> 
Yes</td> 
                <td align="center"><input name="drugs" value="no" type="radio" /> 
No</td> 
                <td align="center">&nbsp;</td> 
              </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left">If Yes, what kind &amp; how often?</td> 
                </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left"><input name="what_drugs" id="what_drugs" size="30" type="text" /></td> 
              </tr> 
              <tr> 
                <td align="left">&nbsp;</td> 
                <td align="left">&nbsp;</td> 
                <td align="left">&nbsp;</td> 
                <td align="left">&nbsp;</td> 
              </tr> 
            </table></td> 
          </tr> 
          <tr> 
            <td ><b>For the Following
              Questions, Please Indicate &#8220;Yes&#8221; &#8220;No&#8221; or &#8220;Do Not Know&#8221;.&nbsp; </b><i>Please
                answer all of the questions.</i></td> 
          </tr> 
          <tr> 
            <td > 
              <table border="0" cellspacing="3" cellpadding="0"> 
            <!--<tr> 
               
               <td><img src="spa.gif" width="180" height="1" /></td> 
                <td><img src="spa.gif" width="100" height="1" /></td> 
                <td align="left"><img src="spa.gif" width="40" height="1" /></td> 
                <td align="center"><img src="spa.gif" width="40" height="1" /></td> 
                <td align="center"><img src="spa.gif" width="100" height="1" /></td> 
              </tr>-->
             
              <tr> 
                <td colspan="2">1.&nbsp;&nbsp; Do you currently take any
                of the following medications?</td> 
                <td align="left">&nbsp;</td> 
                <td align="center">&nbsp;</td> 
                <td align="center">&nbsp;</td> 
              </tr> 
              <tr> 
                <td  align="right" valign="top"><strong>a)&nbsp;</strong></td> 
                <td align="left"> <strong>Aspirin</strong><br /> 
                  (excedrin, anacin,
                bufferin)</td> 
                <td align="left"><input name="aspirin" value="yes" id="aspirin_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="aspirin" value="no" id="aspirin_2" type="radio" /> 
No</td> 
                <td align="center"><input name="aspirin" value="do not know" id="aspirin_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="right" valign="top">&nbsp;</td> 
                <td colspan="4" align="center"></td> 
                </tr> 
              <tr> 
                <td align="right" valign="top"><strong>b)&nbsp;</strong></td> 
                <td align="left"><strong>Anticoagulants</strong><br /> 
                  (blood-thinning
                medicine)</td> 
                <td align="left"><input name="anticoagulants" value="yes" id="anticoagulants_0" type="radio" /> 
Yes</td> 
                <td align="center"><input name="anticoagulants" value="no" id="anticoagulants_1" type="radio" /> 
No</td> 
                <td align="center"><input name="anticoagulants" value="do not know" id="anticoagulants_2" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="right" valign="top">&nbsp;</td> 
                <td colspan="4" align="center"></td> 
                </tr> 
              <tr> 
                <td align="right" valign="top"><strong>c)&nbsp;</strong></td> 
                <td align="left"><strong>Propanol, Verapamil </strong><br /> 
                  (heart
                rhythm medicines)</td> 
                <td align="left"><input name="propanol" value="yes" id="propanol_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="propanol" value="no" id="propanol_2" type="radio" /> 
No</td> 
                <td align="center"><input name="propanol" value="do not know" id="propanol_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="right" valign="top">&nbsp;</td> 
                <td colspan="4" align="center"></td> 
                </tr> 
              <tr> 
                <td align="right" valign="top"><strong>d)&nbsp;</strong></td> 
                <td align="left"><strong>Diuretics </strong><br /> 
                  (water pills)</td> 
                <td align="left"><input name="diuretics" value="yes" id="diuretics_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="diuretics" value="no" id="diuretics_2" type="radio" /> 
No</td> 
                <td align="center"><input name="diuretics" value="do not know" id="diuretics_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="right" valign="top">&nbsp;</td> 
                <td colspan="4" align="center"></td> 
                </tr> 
              <tr> 
                <td align="right" valign="top"><strong>e)</strong></td> 
                <td align="left"><strong>Antihypertensive drugs </strong><br /> 
                  (blood
                pressure pills)</td> 
                <td align="left"><input name="antihypertensive_drugs" value="yes" id="antihypertensive_drugs_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="antihypertensive_drugs" value="no" id="antihypertensive_drugs_2" type="radio" /> 
No</td> 
                <td align="center"><input name="antihypertensive_drugs" value="do not know" id="antihypertensive_drugs_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="right" valign="top">&nbsp;</td> 
                <td colspan="4" align="center"></td> 
                </tr> 
              <tr> 
                <td align="right" valign="top"><strong>f)&nbsp;</strong></td> 
                <td align="left"> <strong>Digitalis</strong><br /> 
                  (heart pills)</td> 
                <td align="left"><input name="digitalis" value="yes" id="digitalis_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="digitalis" value="no" id="digitalis_2" type="radio" /> 
No</td> 
                <td align="center"><input name="digitalis" value="do not know" id="digitalis_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="right" valign="top">&nbsp;</td> 
                <td colspan="4" align="center"></td> 
                </tr> 
              <tr> 
                <td align="right" valign="top"><strong>g)</strong></td> 
                <td align="left"> <strong>Stereoids</strong><br /> 
                  (prednisone,
                cortisone)</td> 
                <td align="left"><input name="stereoids" value="yes" id="stereoids_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="stereoids" value="no" id="stereoids_2" type="radio" /> 
No</td> 
                <td align="center"><input name="stereoids" value="do not know" id="stereoids_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">2.&nbsp;&nbsp;&nbsp; Have
                you ever been treated for cancer with chemotherapy or radiation therapy? </td> 
                <td align="left"><input name="cancer_threatment" value="yes" id="cancer_threatment_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="cancer_threatment" value="no" id="cancer_threatment_2" type="radio" /> 
No</td> 
                <td align="center"><input name="cancer_threatment" value="do not know" id="cancer_threatment_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td>&nbsp;</td> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left">If
                      yes: when:</td> 
                </tr> 
              <tr> 
                <td>&nbsp;</td> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left"><input name="cancer_threatment_when" id="cancer_threatment_when" size="25" type="text" /></td> 
                </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2"> 3.&nbsp;&nbsp; Do you currently have any
                problems with your:</td> 
                <td align="left">&nbsp;</td> 
                <td align="center">&nbsp;</td> 
                <td align="center">&nbsp;</td> 
              </tr> 
              <tr> 
                <td align="right" valign="top"><strong>a)&nbsp;</strong></td> 
                <td align="left"><strong>Liver </strong><br /> 
                  (e.g. cirrhosis,
                hepatitis, yellow jaundice)</td> 
                <td align="left"><input name="liver" value="yes" id="liver_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="liver" value="no" id="liver_2" type="radio" /> 
No</td> 
                <td align="center"><input name="liver" value="do not know" id="liver_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="right" valign="top">&nbsp;</td> 
                <td colspan="4" align="center"></td> 
                </tr> 
              <tr> 
                <td align="right" valign="top"><strong>b)&nbsp;</strong></td> 
                <td align="left"><strong>Kidneys</strong> <br /> 
                  (infection, stones,
                failure)</td> 
                <td align="left"><input name="kidneys" value="yes" id="kidneys_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="kidneys" value="no" id="kidneys_2" type="radio" /> 
No</td> 
                <td align="center"><input name="kidneys" value="do not know" id="kidneys_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="right" valign="top">&nbsp;</td> 
                <td colspan="4" align="center"></td> 
                </tr> 
              <tr> 
                <td align="right"><strong>c)</strong></td> 
                <td align="left"><strong>Spleen</strong></td> 
                <td align="left"><input name="spleen" value="yes" id="spleen_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="spleen" value="no" id="spleen_2" type="radio" /> 
No</td> 
                <td align="center"><input name="spleen" value="do not know" id="spleen_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td align="right">&nbsp;</td> 
                <td colspan="4" align="center"></td> 
                </tr> 
              <tr> 
                <td align="right" valign="top"><strong>d)</strong></td> 
                <td align="left"><strong>Blood </strong><br /> 
                  (anemia, leukemia)</td> 
                <td align="left"><input name="blood" value="yes" id="blood_d2" type="radio" /> 
Yes</td> 
                <td align="center"><input name="blood" value="no" id="blood_d" type="radio" /> 
No</td> 
                <td align="center"><input name="blood" value="do not know" id="blood_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2"> 4.&nbsp;&nbsp; Have you or anyone in your
                family ever had a serious bleeding problem?</td> 
                <td align="left"><input name="bleeding" value="yes" id="bleeding_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="bleeding" value="no" id="bleeding_2" type="radio" /> 
No</td> 
                <td align="center"><input name="bleeding" value="do not know" id="bleeding_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">5.&nbsp;&nbsp; Have you ever had
                prolonged or unusual bleeding from tooth extractions, cut, surgery or
                nosebleed?</td> 
                <td align="left"><input name="unusual_bleeding" value="yes" id="unusual_bleeding_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="unusual_bleeding" value="no" id="unusual_bleeding_2" type="radio" /> 
No</td> 
                <td align="center"><input name="unusual_bleeding" value="do not know" id="unusual_bleeding_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2"> 6.&nbsp;&nbsp; Do your gums bleed when
                you brush your teeth?</td> 
                <td align="left"><input name="gums_bleed" value="yes" id="gums_bleed_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="gums_bleed" value="no" id="gums_bleed_2" type="radio" /> 
No</td> 
                <td align="center"><input name="gums_bleed" value="do not know" id="gums_bleed_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">7.&nbsp;&nbsp; Are you pregnant?</td> 
                <td align="left"><input name="pregnant" value="yes" id="pregnant_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="pregnant" value="no" id="pregnant_2" type="radio" /> 
No</td> 
                <td align="center"><input name="pregnant" value="do not know" id="pregnant_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">8.&nbsp;&nbsp; Is there any possibility
                that you are pregnant?</td> 
                <td align="left"><input name="possibility_pregnant" value="yes" id="possibility_pregnant_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="possibility_pregnant" value="no" id="possibility_pregnant_2" type="radio" /> 
No</td> 
                <td align="center"><input name="possibility_pregnant" value="do not know" id="possibility_pregnant_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">9.&nbsp;&nbsp; Have been told you have
                diabetes?</td> 
                <td align="left"><input name="have_diabetes" value="yes" id="have_diabetes_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="have_diabetes" value="no" id="have_diabetes_2" type="radio" /> 
No</td> 
                <td align="center"><input name="have_diabetes" value="do not know" id="have_diabetes_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">10.&nbsp;&nbsp; Do you wake up to urinate
                more than once at night?</td> 
                <td align="left"><input name="urinate_more_than_1" value="yes" id="urinate_more_than_1_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="urinate_more_than_1" value="no" id="urinate_more_than_1_2" type="radio" /> 
No</td> 
                <td align="center"><input name="urinate_more_than_1" value="do not know" id="urinate_more_than_1_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">11.&nbsp;&nbsp; Do you have muscle cramps
                or pains?&nbsp; </td> 
                <td align="left"><input name="muscle_cramps" value="yes" id="muscle_cramps_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="muscle_cramps" value="no" id="muscle_cramps_2" type="radio" /> 
No</td> 
                <td align="center"><input name="muscle_cramps" value="do not know" id="muscle_cramps_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">12.&nbsp;&nbsp; Do you have problems with
                your lungs or chest? (e.g., chest pain, <br /> 
skipped heart beats, high blood pressure, smoke one or more packs a day, <br /> 
shortness of breath, emphysema, asthma, bronchitis)&nbsp; </td> 
                <td align="left"><input name="lungs_chest" value="yes" id="lungs_chest_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="lungs_chest" value="no" id="lungs_chest_2" type="radio" /> 
No</td> 
                <td align="center"><input name="lungs_chest" value="do not know" id="lungs_chest_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="2">&nbsp;</td> 
                <td colspan="3" align="left"> if yes please list:</td> 
                </tr> 
              <tr> 
                <td colspan="2">&nbsp;</td> 
                <td colspan="3" align="left"><input name="lung_chest_problems" id="lung_chest_problems" size="30" type="text" /></td> 
                </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">13.&nbsp;&nbsp; Do you have a cough, or
                cough frequently?</td> 
                <td align="left"><input name="cough" value="yes" id="cough_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="cough" value="no" id="cough_2" type="radio" /> 
No</td> 
                <td align="center"><input name="cough" value="do not know" id="cough_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">14.&nbsp;&nbsp; Do you have epilepsy or
                suffer from fits or seizures?</td> 
                <td align="left"><input name="epilepsy" value="yes" id="epilepsy_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="epilepsy" value="no" id="epilepsy_2" type="radio" /> 
No</td> 
                <td align="center"><input name="epilepsy" value="do not know" id="epilepsy_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">15.&nbsp; Do you have neck or back
                problems?</td> 
                <td align="left"><input name="neck_back" value="yes" id="neck_back_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="neck_back" value="no" id="neck_back_2" type="radio" /> 
No</td> 
                <td align="center"><input name="neck_back" value="do not know" id="neck_back_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="5" height="15"></td> 
              </tr> 
              <tr> 
                <td colspan="2">16.&nbsp;&nbsp; Are you scheduled to have
                an operation?</td> 
                <td align="left"><input name="scheduled_operation" value="yes" id="scheduled_operation_1" type="radio" /> 
Yes</td> 
                <td align="center"><input name="scheduled_operation" value="no" id="scheduled_operation_2" type="radio" /> 
No</td> 
                <td align="center"><input name="scheduled_operation" value="do not know" id="scheduled_operation_3" type="radio" /> 
Do Not Know</td> 
              </tr> 
              <tr> 
                <td colspan="2">&nbsp;</td> 
                <td colspan="3" align="left">&nbsp;&nbsp;&nbsp;&nbsp; If Yes, what operation?</td> 
                </tr> 
              <tr> 
                <td>&nbsp;</td> 
                <td align="left">&nbsp;</td> 
                <td colspan="3" align="left"><input name="operation_schedule" id="operation_schedule" size="30" type="text" /></td> 
                </tr> 
            </table>              </td> 
          </tr> 
          <tr> 
            <td height="44" align="center" >
			<input type="submit" value="Submit" name="B1" style="width:100px;height:30px;"></td> 
          </tr>
        </table>  
	<div class="clear"></div>
</div>	
</form>


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		<title>Contact Us</title>
		<link>http://www.obesitysolutions.us/contact.htm</link>
		<comments>http://www.obesitysolutions.us/contact.htm#comments</comments>
		<pubDate>Fri, 15 Oct 2010 11:24:15 +0000</pubDate>
		<dc:creator>admin</dc:creator>
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		<description><![CDATA[Title: Mr. Mrs. Miss. Dr. Lic. Mstr. Eng. Name: City: State: AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY Other State for non US residents *Phone Number Mobile: Email: Regarding: procedure available dates locations Cancun or TJ eligibility Message: &#160; How did you find about us? Friend email Newspaper Internet help group Yahoo web search Google web search &#160; &#160; //You should create the validator only after the definition of the HTML form var frmvalidator = new Validator("myform"); frmvalidator.EnableOnPageErrorDisplaySingleBox(); frmvalidator.EnableMsgsTogether(); frmvalidator.addValidation("name","req","Please enter your name"); frmvalidator.addValidation("name","maxlen=40", "Max length for name is 40"); frmvalidator.addValidation("city","req","Enter City"); frmvalidator.addValidation("email","maxlen=50"); frmvalidator.addValidation("email","email", "Invalid Email Address"); frmvalidator.addValidation("email","req","Please enter your email"); frmvalidator.addValidation("telephone","req","Please enter your Phone Number"); frmvalidator.addValidation("telephone","numeric","Invalid Phone numbers " ); frmvalidator.addValidation("mobile","numeric","Invalid Mobile numbers " ); frmvalidator.addValidation("message","req","Please enter your Message"); frmvalidator.addValidation("list","dontselect=0", "Select Regarding");]]></description>
			<content:encoded><![CDATA[<div class="contact-form">
<table id="Table_01" width="600"   border="0" cellpadding="0" cellspacing="0" bgcolor="#c4a571" style="border:0 solid #a2834f;float:left;margin-top:0px;padding:15px;font-size:12px;color:#000">
<tr>
<td  >
<!---->
<form method="POST" action="http://www.obesitysolutions.us/form_contact.php" name="myform" id="myform" > 
<td ><div id='myform_errorloc' class='error_strings'></div> 
	<table border="0" cellpadding="5" id="table1"align="left">
	<tr>
	<td>
							<font>Title:</font></td>
							<td  colspan="2">
							<select name="title" id="select6">
                                                          <option>Mr.</option>
                                                          <option>Mrs.</option>
                                                          <option>Miss.</option>
                                                          <option>Dr.</option>
                                                          <option>Lic.</option>
                                                          <option>Mstr.</option>
                                                          <option>Eng.</option>
                              </select></td>
						</tr>
						<tr>
							<td >
							<font>Name:</font></td>
							<td  colspan="2">
							<input type="text" name="name" size="30"></td>
						</tr>
						<tr>
							<td >
							<font>City:</font></td>
							<td  colspan="2">
							                          <input name="city" type="text" id="city" size="30"></td>
						</tr>
						<tr>
							<td >
							<font>State:</font></td>
							<td colspan="2">
							<select size="1" name="state">
							<option value="AL" selected>AL</option>
                                                        <option value="AK">AK</option> 
                                                        <option value="AZ">AZ</option> 
                                                        <option value="AR">AR</option> 
                                                        <option value="CA">CA</option> 
                                                        <option value="CO">CO</option> 
                                                        <option value="CT">CT</option> 
                                                        <option value="DE">DE</option> 
                                                        <option value="DC">DC</option> 
                                                        <option value="FL">FL</option> 
                                                        <option value="GA">GA</option> 
                                                        <option value="HI">HI</option> 
                                                        <option value="ID">ID</option> 
                                                        <option value="IL">IL</option> 
                                                        <option value="IN">IN</option> 
                                                        <option value="IA">IA</option> 
                                                        <option value="KS">KS</option> 
                                                        <option value="KY">KY</option> 
                                                        <option value="LA">LA</option> 
                                                        <option value="ME">ME</option> 
                                                        <option value="MD">MD</option> 
                                                        <option value="MA">MA</option> 
                                                        <option value="MI">MI</option> 
                                                        <option value="MN">MN</option> 
                                                        <option value="MS">MS</option> 
                                                        <option value="MO">MO</option> 
                                                        <option value="MT">MT</option> 
                                                        <option value="NE">NE</option> 
                                                        <option value="NV">NV</option> 
                                                        <option value="NH">NH</option> 
                                                        <option value="NJ">NJ</option> 
                                                        <option value="NM">NM</option> 
                                                        <option value="NY">NY</option> 
                                                        <option value="NC">NC</option> 
                                                        <option value="ND">ND</option> 
                                                        <option value="OH">OH</option> 
                                                        <option value="OK">OK</option> 
                                                        <option value="OR">OR</option> 
                                                        <option value="PA">PA</option> 
                                                        <option value="RI">RI</option> 
                                                        <option value="SC">SC</option> 
                                                        <option value="SD">SD</option> 
                                                        <option value="TN">TN</option> 
                                                        <option value="TX">TX</option> 
                                                        <option value="UT">UT</option> 
                                                        <option value="VT">VT</option> 
                                                        <option value="VA">VA</option> 
                                                        <option value="WA">WA</option> 
                                                        <option value="WV">WV</option> 
                                                        <option value="WI">WI</option> 
                                                        <option value="WY">WY</option> 
														<option>Other</option>
							  </select></td>
						</tr>
						<tr>
							<td >
							<font>State for non US residents</font></td>
							<td  colspan="2">
							<input name="otherstate" type="text" id="otherstate4" size="14"></td>
						</tr>
						<tr>
							<td >
							<font> <span class="ColorRed">*</span>Phone Number</font></td>
							<td  colspan="2">
							<input type="text" name="telephone" size="30"></td>
						</tr>
						<tr>
							<td>
							<font >Mobile:</font></td>
							<td colspan="2">
							<input type="text" name="mobile" size="30"></td>
						</tr>
						<tr>
							<td >
							<font>Email:</font></td>
							<td  colspan="2">
							<input type="text" name="email" size="30"></td>
						</tr>
						<tr>
							<td >
							<font>Regarding:</font></td>
							<td  colspan="2">
							<span class="TxtNormalText">
                                                        <select name="list" id="select">
                                                    <option>procedure</option>
                                                        <option>available dates</option>
                                                        <option>locations Cancun or TJ</option>
                                                        <option>eligibility</option>
                                                        </select></span></td>
						</tr>
						<tr>
							<td>
							<font>Message:</font></td>
							<td  rowspan="2" colspan="2">
					<textarea name="message" cols="20" rows="4" id="textarea2" style="width:200px;"></textarea></td>
						</tr>
						<tr>
							<td >&nbsp;</td>
						</tr>
						<tr>
				<td >	<font>How did you find about us?</font></td>
							<td  colspan="2">
                                                        <select name="how" id="how">
                                                        <option value="none"></option>
                                                        <option>Friend</option>
                                                        <option>email</option>
                                                        <option>Newspaper</option>
                                                        <option>Internet help group</option>
                                                        <option>Yahoo web search</option>
                                                        <option>Google web search</option>
                              </select></td>
						</tr>
						<tr>
							<td >&nbsp;</td>
							<td >
							<p align="center">
<input type="submit" value="Send" name="Submit" style="font-family: Arial; font-size: 8pt;width:75px;height:30px;"></td>
							<td>&nbsp;
							</td>
							</td>
						</tr>
		  </table>
<input type="hidden" name="iscontact" value="yes">
		  </form>
		</td>
	</tr>
	</table>
<div class="clear"></div>
</div>


<script language="JavaScript" type="text/javascript">
//You should create the validator only after the definition of the HTML form

  var frmvalidator  = new Validator("myform");
 frmvalidator.EnableOnPageErrorDisplaySingleBox();
 frmvalidator.EnableMsgsTogether();

 frmvalidator.addValidation("name","req","Please enter your name");
  frmvalidator.addValidation("name","maxlen=40", "Max length for name is 40");
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  frmvalidator.addValidation("email","maxlen=50");
  frmvalidator.addValidation("email","email", "Invalid Email Address");
  frmvalidator.addValidation("email","req","Please enter your email");
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  frmvalidator.addValidation("list","dontselect=0", "Select Regarding");

</script>

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		<slash:comments>3</slash:comments>
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