Please enter the information indicated below.

How tall are you?

How much do you weigh?

What is your age?

When is your birthdate?

Do you have a history of being obese for two or more years and have you failed more conservative weight-loss alternatives, such as supervised diet, exercise, and behavioral modification programs?

Are you willing to commit to a long-term low-calories (1000-1500 calories per day) supervised diet?

Do you have reasonable weight loss expectations? i.e. Do you accept a goal of losing up to 15% of your body weight after 26 weeks?

Do you feel that you would be able to follow and meet the requirements of participating in this study, including complying with the visit schedule and behavioral modification program? Are you willing to undergo study-specific procedures, such as endoscopy, anesthesia/sedation, x-ray studies, EKG, and laboratory testing (blood draws)?

Are you willing to take prescribed medication to reduce the acid produced by your stomach? (i.e. proton pump inhibitors)

Will you be willing and able to provide written informed consent?

Will you be willing to provide written Authorization for Use and Release of Health and Research Study Information? This will allow your medical information pertaining to this study to be provided to the company sponsoring the study.

Will you be willing to complete pre-placement screening, educational programs and psychological assessment to support that you are an appropriate candidate for this study?

If you are a female of child-bearing potential, are you willing to use contraception and avoid pregnancy during the length of this study (12 months)?

Have you ever had gastrointestinal (GI) surgery other than an uncomplicated appendix or gallbladder removal?

Do you have or have you ever had an bowel obstruction, adhesive peritonitis, and/or a hiatal hernia greater than 2 centimeters?

Have you ever been told that you have a patulous pyloric channel?

Do you have or have you ever had esophageal or GI motility disorders? Explain.

Have you had a myocardial infarction (heart attack) in the past 6 months? Or do you have a cardiac arrhythmia (i.e. atrial fibrillation)? Explain.

Do you have any history of or current symptoms of varices, bowel obstruction, congential or acquired GI anomalies (i.e. atresias, stenosis, strictire, diverticulosis), kindey, liver, or lung disease? Explain in detail.

Do you have any history of or current symptoms of inflammatory bowel disease, such as Crohn's disease or irritable bowel syndrome? Explain.

Do you have any history of or current symptoms os uncontrolled or unstable thyroid disease? Any thyroid disorder? Explain.

Do you have any history or symptoms in the past 24 months of iiritable bowel disease peritonitis, active esophagitis, gastric or duodenal ulceration, GI hemorrhage, or GI bleeding? Explain.

Do you have Type I diabetes?

Have you ever had an intragastric balloon or similar devide placed? In other words, have you ever had any type of balloon placed in your stomach to aid in weight loss? Explain.

Do you currently take any anticoagulants (blood thinners), steroids, aspirin, non-steroidal anti-inflammatory drugs (NSAIDS), or other medications known to be gastric irritants or to reduce GI motility?

If you answered Yes to the previous question, are you willing to discontinue use of those medications for the duration of this study (12 months)?

Do you take any prescription, non-prescription, or over-the-counter weight loss medications or supplements? If yes, provide details.

If you answered Yes to the previous question, are you willing to stop taking those weight loss medications/supplements for the duration of the study?

Is there any possibility that you have an untreated psychiatric or eating disorder, such as major depression, schizophrenia, substance abuse, binge eating disorder, or bulimia? Explain.

Are you currently pregnant, breast-feeding, or do you intend to become pregnant during the duration of the study (12 months)?

Are you currently enrolled in any other investigational drug or device study?

Do you have any serious medical conditions, such as HIV, Hepatitis C, or a cancer diagnosis of any type within the last 5 years? Any other health concerns/issues? Explain.