First Name:

Last Name:

Date of Surgery (mm/dd/yyyy):

Current contact information:

Mailing Address:

City:

State or Province:

Zip (Postal) Code:

Country:

Home Phone:

Work Phone:

Cell Phone:

Email Address:

Post-Op Questions:

Did you have any post-operative complications we are not already aware of? Yes  No
Please list the diagnosis and treatment:

Since your surgery with us, have you taken Lupron®, Synarel®, Zoladex® ^and/_or Depo Provera®? Yes  No
If so, please list the drug(s) and describe why:

Since your surgery with us, have you had another pelvic surgery for any reason, such as a laparoscopy or hysterectomy?
Yes  No
If so, please describe the surgery performed and the findings.  List multiple procedure details separately.

Since your surgery, have you tried to conceive? Yes  No

If yes, were you able to conceive naturally? Yes  No

Also, please tell us the outcome of the pregnancy:

Please rate your quality of life as you are experiencing it NOW, related to any pelvic or abdominal pain:

Symptoms you are STILL experiencing:

Slight - does not require any pain medication
Moderate - requires only non-narcotic pain medication
Severe - requires narcotic pain medication
Crippling - keeps you from performing daily tasks or severely limits your activity at least one day per month   

Pelvic pain (away from your period):
does not apply slight moderate severe crippling

Menstrual cramps:
does not apply slight moderate severe crippling

Painful sex with deep penetration:
does not apply slight moderate severe crippling

Painful bowel movements:
does not apply slight moderate severe crippling

Constipation:
does not apply slight moderate severe crippling

Diarrhea:
does not apply slight moderate severe crippling

Intestinal cramping:
does not apply slight moderate severe crippling

Bladder pain:
does not apply slight moderate severe crippling

Pelvic pain with exercise:
does not apply slight moderate severe crippling

Backache:
does not apply slight moderate severe crippling

Pain during pelvic exam:
does not apply slight moderate severe crippling

Would you be willing to serve as a reference and talk with other women who are considering surgery here at the Center for Endometriosis Care?

Yes, call me at work – number:

Yes, call me at home – number:

Yes, send me an email – address:

No

PERSONAL NOTE:

THE COLLECTION OF THIS DATA IS OF UTMOST IMPORTANCE TO FUTURE ENDOMETRIOSIS PATIENTS AND THE DOCTORS WHO WILL TREAT THEM.  IT TAKES YEARS TO COLLECT VALID INFORMATION REGARDING THE LONG-TERM RESULTS OF SURGERY.  WE HAVE BEEN VERY FORTUNATE TO TAKE CARE OF SO MANY WONDERFUL WOMEN, WHO HAVE SUFFERED SO MUCH AT THE HANDS OF THIS DISEASE; NOW WE NEED TO BE SURE THAT EVERYONE IS INCLUDED IN THE FOLLOW-UP.

PLEASE LET US MAKE COPIES OF YOUR RECORDS BY SIGNING THE FOLLOWING RELEASE.

THANK YOU FOR THE TIME YOU WILL SPEND DOING THIS.

DR. ROBERT B. ALBEE, JR.
DR. KEN SINERVO

 RELEASE

FOR THE PURPOSES OF SCIENTIFIC RESEARCH, I AUTHORIZE RELEASE OF COPIES OF ANY MEDICAL INFORMATION INCLUDING OPERATIVE REPORTS, VIDEOTAPES, PATHOLOGY REPORTS AND OTHER MEDICAL RECORDS TO ROBERT B. ALBEE, JR., MD AND/OR KEN SINERVO, MD, 1140 HAMMOND DRIVE, BUILDING F, SUITE 6220, ATLANTA, GA 30328. 

SIGNED (by typing your full name):

DATED mm/dd/yyyy):