Personal Enquiry & Advice Form - Hiatus Hernia


                        Some Information about You and Your Hernia so we know how to advise you personallly.


 
A completely FREE 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*Male
Female
Title
Name*
                            
                                                    
                                                    First
                                               
                            
                                                    
                                                    Last
                                                
                            
                        
Your Country?*
Address    
                    
                         
                                        
                                        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.
Email*
                                
                                    
                                    Enter Email
                                
                                
                                    
                                    Confirm Email
                                
                                
                            
We need this as will send our reply to this e-mail address
Telephone Number:
Date of Birth*
Age Now (Years)*
Height*
METRES - unless you say otherwise
Weight*
KILOS - unless you say otherwise
Occupation*Working (Full or Part Time)
Retired
Student
Your Occupation:*
The main reason for asking is to know your typical level of physical activity.
What Work Did You do before Retiring?
 
.
Do you have a family doctor (GP)?Yes
No
Your family doctor's name
We will NOT contact your doctor without your prior consent
Your family doctor's address    
                    
                         
                                        
                                        Street Address
                                    
                                        
                                        Address Line 2
                                    
                                    
                                    City
                                 
                                        
                                        State / Province / Region
                                      
                                    
                                    ZIP / Postal Code
                                
                                        
                                        Country
                                    
                    
                
Have you been told that you have a Hiatus Hernia by a DOCTOR?*Yes
No
As it was not diagnosed by a doctor, how do you know you have a hiatus hernia?*
					
				
How was this diagnosed? (Tick all that apply)*
								
								Based upon your symptoms
							

								
								Endoscopy
							

								
								Barium Study
							
Have you been told how big the hernia is?*No
Small
Medium
Large
Extremely Large
Do you suffer from heartburn?*Yes
No
How severe is the heartburn (answer as closely as possible)*Daily
More than 3 times a week
Once a week
Once a month
What type of foods trigger the heartburn?*
					
				
 
.
Do you have any of these other symptoms? (Tick all that apply)*
								
								Chest Pain
							

								
								Upper 'Tummy' Pain
							

								
								Food regurgitation on lying down or bending down (Reflux)
							

								
								Sour taste in the back of the mouth
							

								
								Sore throat in the morning on waking up
							

								
								Hoarse voice in the morning on waking up
							

								
								Breathlessness
							

								
								Difficulty in Swallowing
							

								
								None of these
							
Have you taken any of these medications so far? (Tick all that apply)*
								
								Over the counter- antacids (eg. Gaviscon/ Rennie)
							

								
								Ranitidine
							

								
								Omeprazole/ Lansoprazole/ Pantoprazole/ Esmeprazole
							

								
								Other
							

								
								None
							
Which 'Other' medications have you taken for this condition?*
 
.
Have these medications worked in controlling your symptoms?*Yes
No
How effective have you found these medicines in controlling your symptoms?*VERY Effective
QUITE Effective
SOMEWHAT Effective
What would happen if you were asked to stop the medications?*It would not have any effect on my quality life
It would have slight effect on my quality of life
It would have a severe effect on my quality of life
Have you undergone any surgery for HIATUS HERNIA or ACID REFLUX before?*Yes
No
Have you undergone an endoscopy (a camera test through the mouth)*Yes
No
How long ago did you undergo the endoscopy?*Within the last 12 months
Between 1 and 3 years
Between 4 and 5 years
More than 5 years ago
Have you undergone a barium test (a drink of dye and an x-ray)*Yes
No
How long ago did you undergo the barium test?*Within the last 12 months
Between 1 and 3 years
Between 4 and 5 years
More than 5 years ago
Have you undergone a pH (acid) study (a 24 hour test where a laboratory measures the extent of acid reflux) ?*Yes
No
.
Do you have a copy of the report or can you access the report ?*Yes
No
.

 Thank you. That has been extremely helpful.

All that remains is some (important) information about your general health
.
Have you ever had any serious illness or operations before?*Yes
No
If yes, please give details*
					
				
Have you ever had heart problems?*Yes
No
If yes, please give details*
					
				
Have you ever had blood pressure (high OR low) problems?*Yes
No
If yes, please give details including whether you are taking medication for it*
					
				
Have you ever had breathing or chest problems?*Yes
No
If yes, please give details*
					
				
Do you have any urinary problems ('passing water')?*Yes
No
If yes, please give details*
					
				
Are you taking medication for anything?*Yes
No
If yes, please give details*
					
				
Are you taking aspirin regularly?*Yes
No
Are you taking anticoagulants?*Yes
No
If yes, please give details*
					
				
Are you allergic to any medication?*Yes
No
Which medication(s) are you allergic to?*
					
				
Any other medical condition or facts you think we should be aware of?*Yes
Nothing at all
Any 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?*Yes
No
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.
Name
This field is for validation purposes and should be left unchanged.
                            
          
            
            
            
            
            
            
            
            
            
        
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The British Hernia Centre

The World's Leading Specialist Hernia Centre

Personal Enquiry & Advice Form – Hiatus Hernia
