Post-Operative Follow-Up Questionnaire (1 Month) 1 month 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. 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 .Do you have PAIN now in the area of the hernia (1 month after the procedure)?*YesNo .How would you describe how the area of the hernia feels today on a scale of 1 to 4*1 No more than Mild Discomfort2 A 'Significant' Moderate Ache3 Painful4 Very PainfulAfter the procedure, did you take any painkillers?*YesNoFor how many days did you need painkillers?*Please enter a value between 0 and 30. .Do you have any NUMBNESS at or near the operation site?*YesNoDo you have any NUMBNESS at or near the operation site?*YesNoDo you drive a car?*YesNoAfter how many days did you feel able to drive?* .Have you returned to work?*YesNoI am RetiredAfter how many days were you able to return to work?* .Was it anything to do with the hernia repair that has stopped you going back to work?*YesNo .Can you please explain what it is about the hernia that prevents you from working - and what you do? Have you resumed your usual activities?*YesNo .After how many days were you able to return to your normal activities?* .Nearly done! .If you have not returned to normal activities, what prevents you from doing so? .Please tell us your overall feelings about how your procedure turned out for you. Tell us how happy you are with everything and your return to normal after the operation. .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 WorseFINAL QUESTION! - Was the information you received from us before and after your operation helpful?YesNoPhoneThis field is for validation purposes and should be left unchanged. Δ
