Patient Enquiry Form (Abdominal Wall Hernia) Patient Enquiry Form (Abdominal Wall Hernia) - V.2.1 Some Information about You and Your Hernia so we know how to advise you personallly. A completely FREE information service. It is our pleasure to do whatever we can to help you with any matter concerning HERNIA Please be as accurate as possible and answer all questions. Naturally, all information given will be treated in complete confidence Please Note: To use this form, please ensure your Browser is the latest version and is up-to-date, along with any Javascript or other components. If you have any problems submitting the form, please use a different browser.Gender*MaleFemaleTitleMrDrSirProfessorLordMrsMissLadyOtherTitleMrsDrProfessorMissLadyLordSirMrOtherName* First Last Occupation*Working (Full or Part Time)RetiredStudentYour Occupation:*The main reason for asking is to know your typical level of physical activity.What Work Did You do before Retiring?Your Country?*Select Your CountryUnited KingdomUnited StatesAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFijiFinlandFranceGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorwayNorthern Mariana IslandsOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUruguayVanuatuVatican CityVenezuelaVirgin Islands, BritishVirgin Islands, U.S.ZambiaAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code 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 some cases, it also enables us to give you helpful information on what might be available to you locally. Telephone Number:Email* Enter Email Confirm Email We need this as we will send our reply to this e-mail address. Date of Birth*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Age Now (Years)*Height in METRES*METRES , eg 1.65 (3 digits required including zeros)To convert from FEET & INCHES into Metres: Calculate your height in INCHES Multiply that by 0.0254 eg: 6'1 = 73" 73 x 0.0254 = 1.85 metresWeight in KILOS*KILOS , eg 074.6 (4 digits required including zeros)Do you have a family doctor (GP)?YesNoYour family doctor's nameWe will NOT contact your doctor without your prior consentYour family doctor's address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country It is possible to have more than one hernia. We need to know if you have one hernia right now or more. If more than one, then please give as much information as you can about each of them. OK, got it. Continue How Many Hernias do you Currently Have?*One HerniaTwo HerniasMore than Two Hernias Please think of each hernia as Hernia 1, Hernia 2 etc. That will let us refer to each of them separately from now on...OK, Got it. CONTINUEDescribe where your hernia is, including if it is on (your) LEFT, RIGHT or MIDLINE, UMBILICAL ('the navel') and how close to the groin. The 'Groin' is the line where the legs meet the abdomen, like the two branches on a letter 'Y'."HERNIA 1" Describe where your hernia is, including if it is on (your) LEFT, RIGHT or MIDLINE, UMBILICAL ('the navel') and how close to the groin. The 'Groin' is the line where the legs meet the abdomen, like the two branches on a letter 'Y'."HERNIA 2" Describe where your hernia is, including if it is on (your) LEFT, RIGHT or MIDLINE, UMBILICAL ('the navel') and how close to the groin. The 'Groin' is the line where the legs meet the abdomen, like the two branches on a letter 'Y'."HERNIA 3" Describe where your hernia is, including if it is on (your) LEFT, RIGHT or MIDLINE, UMBILICAL ('the navel') and how close to the groin. The 'Groin' is the line where the legs meet the abdomen, like the two branches on a letter 'Y'.Does it extend into the scrotum?*YesNoDoes "Hernia 1" extend into the scrotum?*YesNoDoes "Hernia 1" extend into the scrotum?*YesNoDoes "Hernia 2" extend into the scrotum?*YesNoDoes "Hernia 2" extend into the scrotum?*YesNoDoes "Hernia 3" extend into the scrotum?*YesNoCan you ever feel a bulge, swelling or lump in the area concerned - whether visible or not - perhaps when you cough?*YesNoAs you never detect any bulge, what makes you think it is a hernia? Or are you just making an educated guess? (Which is perfectly fine) How large is your hernia? Choose one...Too Small to SayPeaEggPlumOrangeMelonOtherIn your own words, describe how large this hernia can be How large is "Hernia 1" (of 2)? Choose one...Too Small to SayPeaEggPlumOrangeMelonOtherIn your own words, describe how large "Hernia 1" (of 2) can be How large is "Hernia 2" (of 2)? Choose one...Too Small to SayPeaEggPlumOrangeMelonOtherIn your own words, describe how large "Hernia 2" (of 2) can be How large is "Hernia 1" (of 3)? Choose one...Too Small to SayPeaEggPlumOrangeMelonOtherIn your own words, describe how large "Hernia 1" (of 3) can be How large is "Hernia 2" (of 3)? Choose one...Too Small to SayPeaEggPlumOrangeMelonOtherIn your own words, describe how large "Hernia 2" (of 3) can be How large is "Hernia 3"? Choose one...Too Small to SayPeaEggPlumOrangeMelonOtherIn your own words, describe how large "Hernia 3" can be Do you have a hernia that does NOT go - or be pushed - back in completely?*YesNoPlease 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 'NO'Do you have a hernia that does NOT go - or be pushed - back in completely?*YesNoPlease 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 'NO'Does the hernia area give Pain or Discomfort?YesNeverHow bad is the pain or discomfort and what, if anything, brings it on? How long have you had this/these hernias?* Has THIS hernia (or any of these hernias) ever been repaired before?*YesNoWhich have been operated on for previous recurrence(s)? (Tick all that apply) Hernia 1 Hernia 2 Hernia 3 Please give approximate dates and indicate if any of the previous repairs were 'keyhole' surgery repairs Have you ever had any serious illness or operations before?*YesNoIf yes, please give details* Is this hernia in the area of the scar from a previous operation?*YesNoHow close is it?Thank you. Nearly there. The information provided above should give us a good idea of your hernia situation. The following questions relate to your general health and are very important. When you get to the end, please just hit the SUBMIT button.Have you ever had heart problems?*YesNoIf yes, please give details* Have you ever had blood pressure (high OR low) problems?*YesNoIf yes, please give details including whether you are taking medication for it* Have you ever had breathing or chest problems?*YesNoIf yes, please give details* Do you have any urinary problems ('passing water')?*YesNoIf yes, please give details* Are you taking medication for anything?*YesNoIf yes, please give details* Are you taking aspirin regularly?*YesNoAre you taking anticoagulants?*YesNoIf yes, please give details* Are you allergic to any medication?*YesNoIf yes, please give details* Any other medical condition or facts you think we should be aware of?*YesNothing at allAny other medical condition or facts Confidentiality and Data Protection I Agree Please note that we will retain your contact details including your email address solely for the purpose of communicating with you in connection with your case. We will protect all data under the strictest terms of patient confidentiality.Do you have health insurance?*YesNoNote: We will NOT contact anybody, this is for our purposes alone.Who are you with? eg: BUPA, Aviva, Blue Cross Blue Shield (USA) etc*Note: We will NOT contact anybody, this is for our purposes alone.PhoneThis field is for validation purposes and should be left unchanged. Δ
