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Patient Follow-up Questionnaire

First Name *
Last Name *
Date of Surgery * Select Date
  
Current Contact Info.:  
Mailing Address
City
State or Province
Zip (Postal) Code
Country
Home Phone
Work Phone
Cell Phone
E-mail 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 Lupon, 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 painawful
poor
fair
good
terrific
  

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 mont

Pelvic pain (away from your period)does not apply
slight
moderate
severe
crippling
Menstrual crampsdoes not apply
slight
moderate
severe
crippling
Painful sex with deep penetrationdoes not apply
slight
moderate
severe
crippling
Painful bowel movementsdoes not apply
slight
moderate
severe
crippling
Constipationdoes not apply
slight
moderate
severe
crippling
Diarrheadoes not apply
slight
moderate
severe
crippling
Intestinal crampingdoes not apply
slight
moderate
severe
crippling
Bladder paindoes not apply
slight
moderate
severe
crippling
Pelvic pain with exercisedoes not apply
slight
moderate
severe
crippling
Backachedoes not apply
slight
moderate
severe
crippling
Pain during pelvic examdoes 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 workYes
Number
Yes, call me at homeYes
Number
Yes, send me an email
No, please do not contact meNo
  

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 *
Today's Date * Select Date

* Required