ÿþ<!DOCTYPE html PUBLIC "-//w3c//dtd html 4.0 transitional//en"> <html> <head> <meta http-equiv="Content-Type" content="text/html; charset=iso-8859-1"> <meta name="GENERATOR" content="Mozilla/4.6 (Macintosh; I; PPC) [Netscape]"> <meta name="Content-Type" content="text/html; charset=iso-8859-1"> <title>Hernia Questions</title> </head> <body background="BHCLogo.GIF"> <center> <h1><font color="#0000ff">T<font size="+2">HE</font> B<font size="+2">RITISH</font> H<font size="+2">ERNIA</font> C<font size="+2">ENTRE</font></font></h1> </center> <center><img src="graylogo.gif" border="1" height="124" width="228"></center> <center> <h2><font color="#000000">Some Information about You </font>and Your Hernia</h2> </center> <center> <h2>So we know how to advise you</h2> </center> <center>A completely FREE service</center> <hr> <ul> <li>Please complete this form so we will know some relevant facts and help you as appropriate to your case.</li> <li>Please be as accurate as possible and answer all questions.</li> <li>Naturally, all information given will be treated in complete confidence.</li> </ul> <center> <hr size="10"><!--=================================--><!--<form method=POST action="http://cgi.www.hernia.org/cgi-bin/www.hernia.org/form-mail.pl">--> <form method="post" action="http://www.hernia.org/cgi-bin/FormMail.pl"><input name="recipient" value="experts@hernia.org" type="hidden"><!--=================================--> <center> <table bgcolor="#ffffff" border="1" cols="1" width="70%"> <tbody> <tr> <td align="center" valign="CENTER"><font color="#cc0000"><font size="+2">It is our pleasure to do whatever we can to help you</font></font> <br> <font color="#cc0000"><font size="+2">with any matter concerning HERNIA.</font></font></td> </tr> </tbody> </table> </center> <br> &nbsp; <table width="95%"> <tbody> <tr> <td><font color="#0000ff">Your Title:&nbsp;</font></td> <td colspan="2"> <select name="title" onchange="title" size="1"> <option value="Mr" selected="selected"><!--OPTION value="Mr"-->Mr</option> <option value="Mrs">Mrs</option> <option value="Miss">Miss</option> <option value="Dr">Dr</option> <option value="Prof">Prof</option> <option value=" ">Other&nbsp;</option> </select> </td> </tr> <tr> <td><font color="#0000ff">First name:&nbsp;</font></td> <td colspan="2"><input name="first" size="20" maxlength="20" type="text"><font color="#0000ff">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; MI:&nbsp;<input name="MI" size="3" maxlength="3" type="text">&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Surname (last name):&nbsp;</font><input name="surname" size="20" maxlength="25" type="text"></td> </tr> <tr> <td nowrap="nowrap"><font color="#0000ff">Your Occupation:</font> <br> <b><font color="#ff0000">(Very important!)</font></b></td> <td colspan="2" nowrap="nowrap"><input name="job" size="40" maxlength="45" type="text"><b><font color="#ff0000">Please state if 'Retired', and what you USED to do.</font></b></td> </tr> <tr> <td><b><font color="#0000ff">Please give us your</font></b> <br> <b><font color="#0000ff">postal address:</font></b></td> <td colspan="2" width="20%"><b><font color="#ff0000">Important: </font></b><font color="#330000">We will NOT approach you or give out <i>any</i> 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&nbsp; information on what might be available to you locally.</font></td> </tr> <tr> <td><font color="#0000ff">Address Line 1:</font></td> <td><input name="adr1" size="30" maxlength="45" type="text"></td> <td rowspan="4" valign="top"><font color="#330000">Forms which are submitted with missing information will not be dealt with as fully and may be delayed.</font> <p><font color="#330000">It is in <b><u>your</u></b> interest to give as much information as possible, leaving no blanks.</font> </p> <p><font color="#330000">Fully complete forms receive priority.</font></p> </td> </tr> <tr> <td><font color="#0000ff">Address Line 2:</font></td> <td><input name="adr2" size="30" maxlength="45" type="text"></td> </tr> <tr> <td><font color="#0000ff">Town / City:&nbsp;</font></td> <td><input name="city" size="28" maxlength="30" type="text"></td> </tr> <tr> <td><font color="#0000ff">State (if applicable)&nbsp;</font></td> <td><input name="state" size="23" maxlength="25" type="text"></td> </tr> <tr> <td><font color="#0000ff">Postal / "ZIP" Code:&nbsp;</font></td> <td><input name="zip" size="24" maxlength="30" type="text"></td> <td><br> </td> </tr> <tr> <td><font color="#0000ff">Country:&nbsp;</font></td> <td><input name="country" size="31" maxlength="40" type="text"></td> <td><br> </td> </tr> <tr> <td><font color="#0000ff"><b>Telephone</b> Number</font> <br> <font color="#0000ff">(Including Country Code):</font></td> <td><input name="phone" size="31" maxlength="31" type="text"> </td> <td><br> </td> </tr> <tr> <td><font color="#0000ff"><b>Fax</b> Number . . .&nbsp;</font> <br> <font color="#0000ff">(Including Country Code):&nbsp;</font></td> <td><input name="fax" size="31" maxlength="30" type="text"></td> <td><br> </td> </tr> <tr> <td colspan="3"><a name="emailcheck"></a> <center> <table bgcolor="#ffffcc" border="1" cols="1" width="100%"> <tbody> <tr> <td> <center><font color="#0000ff">Your <b>E-Mail</b> Address:&nbsp;<input name="email" size="45" maxlength="60" type="text"></font><b><font color="#ff0000">&nbsp; Type carefully!</font></b></center> </td> </tr> <tr> <td> <center><b><font color="#ff0000">IT IS <i>ESSENTIAL</i> that you make no mistake here or we will simply not be able to reply to you!&nbsp;</font></b> <br> <b><font color="#ff0000">* * *&nbsp;</font></b> <br> <b><font color="#000000">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.</font></b></center> </td> </tr> </tbody> </table> </center> </td> </tr> <tr> <td><font color="#0000ff">Date of Birth: </font><font color="#000000">(dd/mm/yy)</font></td> <td><input name="dob" size="20" maxlength="20" type="text"></td> <td><br> </td> </tr> <tr> <td> <br> <font color="#0000ff">Age now (years):&nbsp;</font></td> <td valign="CENTER"><input name="age" size="5" maxlength="5" type="text"></td> <td><br> </td> </tr> <tr> <td><font color="#0000ff">Height:</font></td> <td colspan="2"><input name="height" size="10" maxlength="10" type="text"><font color="#0000ff">(<b>metres</b> - <i>unless you say otherwise</i>)</font></td> </tr> <tr> <td><font color="#0000ff">Weight:</font></td> <td colspan="2"><input name="weight" size="10" maxlength="10" type="text"><font color="#0000ff">(<b>kilos</b> - <i>unless you say otherwise</i>)</font></td> </tr> <tr> <td colspan="3"><img src="colourbar.gif" nosave="" border="0" height="5" width="600"></td> </tr> <tr> <td colspan="2"><font color="#0000ff">Your family doctor's name:&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Dr:</font></td> <td><input name="drname" size="34" maxlength="25" type="text"></td> </tr> <tr> <td colspan="2"><font color="#0000ff">Your family doctor's address line 1:</font></td> <td><input name="draddress1" size="30" maxlength="45" type="text"></td> </tr> <tr> <td colspan="2"><font color="#0000ff">Your family doctor's address line 2:</font></td> <td><input name="draddress2" size="30" maxlength="45" type="text"></td> </tr> <tr> <td colspan="2"><font color="#0000ff">Your family doctor's address line 3:</font></td> <td><input name="draddress3" size="30" maxlength="45" type="text"></td> </tr> </tbody> </table> <p><img src="colourbar.gif" nosave="" border="0" height="5" width="600"> <br> &nbsp; </p> <p><font color="#0000ff"><b>Where</b> is your hernia ?:&nbsp; <select name="wherehernia1" onchange="wherehernia1" size="1"> <option value="" selected="selected">select from here&nbsp;</option> <option value="L GROIN">Left Groin&nbsp;</option> <option value="R GROIN">Right Groin</option> <option value="BILATERAL">Both Groins</option> <option value="UMBILICAL">Umbilicus ("Navel")</option> <option value="EPIGASTRIC/VENTRAL">Above the Umbilicus ("Navel")</option> <option value="INCISIONAL">At the site of a previous operation</option> <option value="HIATUS">HIATUS Hernia</option> <option value="other type">Other</option> </select> </font></p> <p><font color="#0000ff"><font color="#0000ff">If your hernia is <b><u>not</u></b> 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)</font> </font></p> <p><font color="#0000ff"><font color="#0000ff">&nbsp;If you have more than one hernia, please give the information for EACH of them wherever appropriate.</font> </font></p> <p><font color="#0000ff"><textarea name="wherehernia2" rows="8" cols="65"></textarea><br> &nbsp; <table> <tbody> <tr> <td><font color="#0000ff">Does it extend into the <b>scrotum</b>?&nbsp;</font></td> <td><font color="#0000ff">Yes<input name="scrot" value="scrotal hernia" type="radio"> No&nbsp;</font><input name="scrot" value="not scrotal" type="radio"></td> </tr> <tr> <td><font color="#0000ff">Is there ever a <b>bulge</b> -</font> <br> <font color="#0000ff">when you stand or cough, for example?</font></td> <td><font color="#0000ff">Yes<input name="bulge" value="BULGES" type="radio">No&nbsp;</font><input name="bulge" value="NO BULGE" type="radio"></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff"><b>How long </b>have you had this hernia?</font></td> <td><input name="time" size="40" maxlength="45" type="text"></td> </tr> <tr> <td><font color="#0000ff"><b>How large</b> is your hernia ?</font></td> <td> <select name="sizehernia" onchange="sizehernia" size="1"> <option value="" selected="selected">Select from Here</option> <option value="pea">Pea&nbsp;</option> <option value="egg">Egg</option> <option value="plum">Plum</option> <option value="orange">Orange</option> <option value="melon">Melon</option> <option value="Other">Other (See Box Below)&nbsp;</option> </select> </td> </tr> <tr> <td colspan="2">If your hernia is <b><u>not</u></b> one of the above sizes, please describe how big your hernia is (type in the box below)</td> </tr> <tr> <td nowrap="nowrap"><br> </td> <td><textarea name="sizehernia2" rows="4" cols="25"></textarea></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff">Does it go, or can you push it <b>back in</b> completely ?</font> <br> <font color="#0000ff">(Even if it comes right out again)</font></td> <td><font color="#0000ff">Yes<input name="reduce" value="reducible" type="radio"> No&nbsp;</font><input name="reduce" value="NOT REDUCIBLE!!!" type="radio"></td> </tr> <tr> <td colspan="2"><font color="#000000"><b>Please Note:</b> This is a very important question.</font> <br> <font color="#000000">We must establish if the hernia has become 'trapped'.</font> <br> <font color="#000000">If you (or your doctor) CAN manage to negotiate it back</font> <br> <font color="#000000">inside, even if with difficulty, then please answer 'YES'</font></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff">Has <b>THIS</b> hernia ever been repaired before?</font></td> <td><font color="#0000ff">Yes&nbsp;<input name="recur" value="RECURRENT!!!" type="radio"></font><font color="#000000">(see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="recur" value="PRIMARY" type="radio"></td> </tr> <tr> <td>If it has, please state how many times (before)</td> <td><textarea name="recurnumb" rows="4" cols="25"></textarea></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff">Have you ever had <b>any serious illness</b></font> <br> <font color="#0000ff">or <b>operations</b> before?</font></td> <td><font color="#0000ff">Yes<input name="previous" value="SERIOUS PREVIOUS HISTORY" type="radio"></font><font color="#000000">(see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="previous" value="no previous" type="radio"></td> </tr> <tr> <td>If yes, please give details</td> <td><textarea name="previoushistory" rows="10" cols="45"></textarea></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff">Have you ever had <b>heart</b> problems?</font></td> <td><font color="#0000ff">Yes&nbsp;<input name="heart" value="HEART HISTORY!!!" type="radio"></font><font color="#000000">(see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="heart" value="heart-no history" type="radio"></td> </tr> <tr> <td>If yes, please give details</td> <td><textarea name="heartb" rows="10" cols="45"></textarea></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff">Have you ever had</font> <br> <font color="#0000ff"><b>blood pressure (high OR low)</b> problems?</font></td> <td><font color="#0000ff">Yes&nbsp;<input name="bp" value="BLOOD-PRESSURE PROBLEMS!!!" type="radio"></font><font color="#000000">(see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="bp" value="bp-ok" type="radio"></td> </tr> <tr> <td>If yes, please give details <br> including whether you are taking medication for it</td> <td><textarea name="bpb" rows="10" cols="45"></textarea></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff">Have you ever had <b>breathing</b> <b>or chest</b> problems?</font></td> <td><font color="#0000ff">Yes&nbsp;<input name="resp" value="RESPIRITORY PROBLEMS!!!" type="radio"></font><font color="#000000">(see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="resp" value="resp-ok" type="radio"></td> </tr> <tr> <td>If yes, please give details&nbsp;</td> <td><textarea name="respb" rows="10" cols="45"></textarea></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff">Do you have any <b>urinary</b> problems ('passing water')?</font></td> <td><font color="#0000ff">Yes&nbsp;<input name="wee" value="URINE PROBLEMS!!!" type="radio"></font><font color="#000000">(see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="wee" value="urine-ok" type="radio"></td> </tr> <tr> <td>If yes, please give details&nbsp;</td> <td><textarea name="weeb" rows="10" cols="45"></textarea></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff">Are you taking <b>medication</b> for anything?</font></td> <td><font color="#0000ff">Yes&nbsp;<input name="med" value="ON MEDICATION!!!" type="radio"></font><font color="#000000"> (see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="med" value="no medication" type="radio"></td> </tr> <tr> <td>If yes, please give details</td> <td><textarea name="medb" rows="10" cols="45"></textarea></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff">Are you taking <b>aspirin</b> regularly?</font></td> <td><font color="#0000ff">Yes<input name="asp" value="TAKES ASPIRIN!!!" type="radio"> No&nbsp;</font><input name="asp" value="not on aspirin" type="radio"></td> </tr> <tr> <td><font color="#0000ff">Are you taking <b>anticoagulants</b></font> <br> <font color="#0000ff">(blood thinning tablets, eg Warfarin) ?</font></td> <td><font color="#0000ff">Yes<input name="warf" value="TAKING WARFIRIN!!!" type="radio"> No&nbsp;</font><input name="warf" value="not on warfarin" type="radio"></td> </tr> <tr> <td><font color="#0000ff">Are you <b>allergic</b> to any medication</font> <br> <font color="#0000ff">- eg antibiotics, penicillin, etc?</font></td> <td><font color="#0000ff">Yes<input name="allerg" value="HAS ALLERGIES!!!" type="radio"></font><font color="#000000">(see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="allerg" value="no allergies" type="radio"></td> </tr> <tr> <td><font color="#000000">If yes, please give details</font></td> <td><textarea name="allergb" rows="10" cols="45"></textarea></td> </tr> <tr> <td colspan="2"> <hr width="100%"></td> </tr> <tr> <td><font color="#0000ff"><b>Any other medical condition</b> or</font> <br> <font color="#0000ff">facts you think we should be aware of?</font> <br> <font color="#0000ff">Do you have any specific <b>questions</b> in relation</font> <br> <font color="#0000ff">to the case you have described here?</font></td> <td><font color="#0000ff">Yes<input name="other" value="HAS OTHER PROBLEMS!!!" type="radio"></font><font color="#000000">(see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="other" value="no other problems" type="radio"></td> </tr> <tr> <td>If yes, please give details&nbsp;</td> <td><textarea name="otherb" rows="10" cols="45"></textarea></td> </tr> <tr> <td colspan="2" valign="top"> <hr size="2" width="100%"><br> </td> </tr> <tr> <td valign="top"><font color="#0000ff"><font color="#0000ff">Do you have health insurance?<br> </font></font></td> <td valign="top"><font color="#0000ff"><font color="#0000ff">Yes<input name="other" value="HAS INSURANCE" type="radio"></font><font color="#000000">(see next box)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; </font><font color="#0000ff">No&nbsp;</font><input name="ins" value="no insurance" type="radio"></font><font color="#0000ff"><font color="#0000ff"><font color="#000000">(I am uninsured)</font></font></font></td> </tr> <tr> <td valign="top"><font color="#000000">If yes, please give details,<br> eg: BUPA, Norwich Union, Blue Cross Blue Shield (USA) etc<br> <br> <i>Note: We will NOT contact anybody, this is for our purposes alone.</i><br> <br> </font></td> <td valign="top"><font color="#0000ff"><textarea name="insb" rows="10" cols="45"></textarea></font></td> </tr> </tbody> </table> </font></p> <center> <div align="center"> <table border="1" cols="1" width="70%"> <tbody> <tr> <td align="center" bgcolor="#ffffcc" valign="CENTER"> <center><img src="colourbar.gif" align="middle" height="20" width="30%"><input value="SUBMIT THIS FORM" type="submit"><img src="colourbar.gif" align="middle" height="20" width="30%"> <p>(If it is COMPLETE!) <br> <b><font color="#ff0000"><font size="+1"><u>NOTE: </u>If you have made even the <i>slightest</i> mistake</font></font></b> <br> <b><font color="#ff0000"><font size="+1">in the way you typed your e-mail address above,</font></font></b> <br> <b><font color="#ff0000"><font size="+1">you will not receive any reply from us.</font></font></b> <br> <b><font color="#ff0000"><font size="+1">This is the most common&nbsp; cause for failure in&nbsp; communications.</font></font></b></p> </center> <b><font color="#ff0000"><font size="+1">It is worth checking!</font></font></b> <p><b><font color="#ff0000"><font size="+1">(Click <a href="#emailcheck">here</a> to check)</font></font></b> <br> &nbsp;</p> </td> </tr> </tbody> </table> </div> <center> <p><font color="#0000ff"><img src="letter.gif"><br> <font color="#0000ff">When completed, you can submit this form <i>on-line</i> by clicking the <b>SUBMIT</b> button, above,</font> <br> <font color="#0000ff">or <b>print it</b> and <b>fax it to us on</b></font><b><font color="#000000"> +44 20 8202 6714</font><font color="#0000ff"> (020- 8202 6714 in the UK)</font></b></font></p> </center> <center> <table border="1" cols="1" width="40%"> <tbody> <tr> <td bgcolor="#000000"> <center><font color="#ffff99">Please allow us time to process the details and&nbsp; we will e-mail you back to the address</font> <br> <b><font color="#ffff99">you entered above</font></b> <br> <font color="#ffff99">with information and/or advice and, if appropriate, the cost of the procedure you would require.</font></center> </td> </tr> </tbody> </table> </center> <center><font color="#0000ff"><font color="#0000ff">In case there are problems with e-mail, </font><font color="#ff0000"><b>keep a printed copy, anyway,</b> </font><font color="#0000ff">that could be faxed if necessary.</font> <br> <font color="#0000ff">If you do not hear from us within a very short time, please e-mail us again or telephone us.</font> <br> <img src="phone.gif"><b> You can, of course, telephone us on <font color="#000000">+ 44 20 8201 7000</font></b> <br> <b>(020-8201 7000 in the UK)</b></font></center> <p><font color="#0000ff"><br> </font></p> <center> <table bgcolor="#ffffff" border="1" cols="1" width="70%"> <tbody> <tr> <td align="center" valign="CENTER"> <center><b><font color="#ff0000"><font size="+2">Thank you!</font></font></b></center> <font color="#cc0000"><font size="+2">It is our pleasure to do whatever we can to help you</font></font> <br> <font color="#cc0000"><font size="+2">with any matter concerning HERNIA.</font></font></td> </tr> </tbody> </table> </center> <center><!--INPUT TYPE="SUBMIT" VALUE= "SUBMIT THIS FORM"--><!--br--> <font color="#0000ff"><br> &nbsp; <br> &nbsp; </font> <hr size="10"><font color="#0000ff"><font color="#ff0000">If you need to erase all the information you have entered and start again, click this Reset button:&nbsp;</font><input type="reset"> </font> <hr size="10"> <p><font color="#0000ff"><b><font color="#ff0000"><a href="mailto:The%20British%20Hernia%20Centre FORMS<experts@hernia.org">Click here to E-Mail us </a></font><font color="#000000">(experts@hernia.org) with any questions or general comments</font></b> <br> <b><font color="#000000">not covered in the above form.</font></b> </font></p> <hr size="5"></center> <address> <font color="#999999">Form for Hernia Information Version 2.9,2</font></address> <address> <font color="#999999">&copy; 2009&nbsp; The British Hernia Centre</font></address> <address> <font color="#999999">http://www.hernia.org</font></address> </center> </form> </center> </body> </html>