Post-Operative Follow-Up Questionnaire (1 Year) 1 year post-op CONFIDENTIAL It is important to us and to your continuing care that we know how well you are now and how you have been since the procedure we were happy to perform for you. We would like to know certain details of your current condition. The vast majority of our patients have recovered completely within a very few months after their hernia repair. In a few instances there are still some residual symptoms after that. If this is the case we would like to know about it. Please be as accurate as possible and answer all questions. Naturally, all information given will be treated in complete confidence Please Type Your Reference*This needs to be typed-in EXACTLY in order to continue .Title*Please Select...MrDrSirProfessorLordMrsMissLadyOtherName* First Last Telephone Number:Email* Enter Email Confirm Email .In the LAST WEEK did you have any pain in the area of the hernia repair?*0 No Pain1 Mild Discomfort2 A 'Significant' Moderate Ache3 Painful4 Very PainfulHow much did your symptoms in the LAST WEEK interfere with your normal work or day-to-day activities?*0 Not at all1 Only slight interference - manageable2 Quite a lot of inconvenience and I need painkillersDuring the past 4 weeks, how many days did you cut down on the things you usually do (work, housework, recreational activities) because of any hernia-related symptoms you may still have?*0 None - carried on as normal1 Between 1 - 5 days2 Between 6 - 12 days3 Between 13 - 21 days4 More than 21 days .Have you had pain in a testicle since the procedure?*YesNoI am FemaleRight NOW, do you have any NUMBNESS at or near the operation site or top of the thigh?*YesNo .How would you describe the results of your operation?5 Excellent4 Very Good3 Good2 Fair1 PoorOverall, how are your hernia problems now, compared to before your operation?5 MUCH Better4 A Little Better3 About the Same2 A Little Worse1 MUCH WorseNameThis field is for validation purposes and should be left unchanged. Δ
