THE BRITISH HERNIA CENTRE

Some Information about You and Your Hernia

So we know how to advise you

A completely FREE service

Please complete this form so we will know some relevant facts and help you as appropriate to your case.
Please be as accurate as possible and answer all questions.
Naturally, all information given will be treated in complete confidence.

It is our pleasure to do whatever we can to help you
with any matter concerning HERNIA.

Your Title:

First name:

MI: Surname (last name):

Your Occupation:
(Very important!)

Please state if 'Retired', and what you USED to do.

Please give us your
postal address:

Important: We will NOT approach you or give out any of these details. We ask for them in case you want to correspond with us later. In many cases, it also enables us to give you helpful information on what might be available to you locally.

Address Line 1:

Forms which are submitted with missing information will not be dealt with as fully and may be delayed.

It is in your interest to give as much information as possible, leaving no blanks.

Fully complete forms receive priority.

Address Line 2:

Town / City:

State (if applicable)

Postal / "ZIP" Code:

Country:

Telephone Number
(Including Country Code):

Fax Number . . .
(Including Country Code):

Your E-Mail Address: Type carefully!

IT IS ESSENTIAL that you make no mistake here or we will simply not be able to reply to you!
* * *
If you do not have an e-mail address for the reply, please FAX us the form and we will FAX you back our reply.

Date of Birth: (dd/mm/yy)

Age now (years):

Height:

(metres - unless you say otherwise)

Weight:

(kilos - unless you say otherwise)

Your family doctor's name: Dr:

Your family doctor's address line 1:

Your family doctor's address line 2:

Your family doctor's address line 3:

Where is your hernia ?:

If your hernia is not in one of the above places, or to give more explanation, please describe exactly where you have your hernia. (Please type in the box below)

If you have more than one hernia, please give the information for EACH of them wherever appropriate.

Does it extend into the scrotum? Yes No

Is there ever a bulge -
when you stand or cough, for example? YesNo

How long have you had this hernia?

How large is your hernia ?

If your hernia is not one of the above sizes, please describe how big your hernia is (type in the box below)

Does it go, or can you push it back in completely ?
(Even if it comes right out again) Yes No

Please Note: This is a very important question.
We must establish if the hernia has become 'trapped'.
If you (or your doctor) CAN manage to negotiate it back
inside, even if with difficulty, then please answer 'YES'

Has THIS hernia ever been repaired before? Yes (see next box)        No

If it has, please state how many times (before)

Have you ever had any serious illness
or operations before? Yes(see next box)        No

If yes, please give details

Have you ever had heart problems? Yes (see next box)        No

If yes, please give details

Have you ever had
blood pressure (high OR low) problems? Yes (see next box)        No

If yes, please give details
including whether you are taking medication for it

Have you ever had breathing or chest problems? Yes (see next box)        No

If yes, please give details

Do you have any urinary problems ('passing water')? Yes (see next box)        No

If yes, please give details

Are you taking medication for anything? Yes (see next box)       No

If yes, please give details

Are you taking aspirin regularly? Yes No

Are you taking anticoagulants
(blood thinning tablets, eg Warfarin) ? Yes No

Are you allergic to any medication
- eg antibiotics, penicillin, etc? Yes(see next box)       No

If yes, please give details

Any other medical condition or
facts you think we should be aware of?
Do you have any specific questions in relation
to the case you have described here? Yes(see next box)       No

If yes, please give details

Do you have health insurance?
Yes(see next box)       No (I am uninsured)

If yes, please give details,
eg: BUPA, Norwich Union, Blue Cross Blue Shield (USA) etc

Note: We will NOT contact anybody, this is for our purposes alone.

(If it is COMPLETE!)
NOTE: If you have made even the slightest mistake
in the way you typed your e-mail address above,
you will not receive any reply from us.
This is the most common cause for failure in communications.

It is worth checking!

(Click here to check)

When completed, you can submit this form on-line by clicking the SUBMIT button, above,
or print it and fax it to us on +44 181 202 6714 (0181-202 6714 in the UK)

Please allow us time to process the details and we will e-mail you back to the address
you entered above
with information and/or advice and, if appropriate, the cost of the procedure you would require.

In case there are problems with e-mail, keep a printed copy, anyway, that could be faxed if necessary.
If you do not hear from us within a very short time, please e-mail us again or telephone us.

You can, of course, telephone us on + 44 20 8201 7000
(020-8201 7000 in the UK)

Thank you! It is our pleasure to do whatever we can to help you
with any matter concerning HERNIA.

If you need to erase all the information you have entered and start again, click this Reset button:

Click here to E-Mail us (experts@hernia.org) with any questions or general comments
not covered in the above form.

Form for Hernia Information Version 2.9,1

http://www.hernia.org

Does it extend into the scrotum?	Yes No
Is there ever a bulge - when you stand or cough, for example?	YesNo

How long have you had this hernia?
How large is your hernia ?
If your hernia is not one of the above sizes, please describe how big your hernia is (type in the box below)


Does it go, or can you push it back in completely ? (Even if it comes right out again)	Yes No
Please Note: This is a very important question. We must establish if the hernia has become 'trapped'. If you (or your doctor) CAN manage to negotiate it back inside, even if with difficulty, then please answer 'YES'

Has THIS hernia ever been repaired before?	Yes (see next box) No
If it has, please state how many times (before)

Have you ever had any serious illness or operations before?	Yes(see next box) No
If yes, please give details

Have you ever had heart problems?	Yes (see next box) No
If yes, please give details

Have you ever had blood pressure (high OR low) problems?	Yes (see next box) No
If yes, please give details including whether you are taking medication for it

Have you ever had breathing or chest problems?	Yes (see next box) No
If yes, please give details

Do you have any urinary problems ('passing water')?	Yes (see next box) No
If yes, please give details

Are you taking medication for anything?	Yes (see next box) No
If yes, please give details

Are you taking aspirin regularly?	Yes No
Are you taking anticoagulants (blood thinning tablets, eg Warfarin) ?	Yes No
Are you allergic to any medication - eg antibiotics, penicillin, etc?	Yes(see next box) No
If yes, please give details

Any other medical condition or facts you think we should be aware of? Do you have any specific questions in relation to the case you have described here?	Yes(see next box) No
If yes, please give details

Do you have health insurance?	Yes(see next box) No (I am uninsured)
If yes, please give details, eg: BUPA, Norwich Union, Blue Cross Blue Shield (USA) etc Note: We will NOT contact anybody, this is for our purposes alone.