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Patient Follow-up Questionnaire
Please note: should you experience any difficulty transmitting this form, please email the data directly to Heather@CenterForEndo.com. Thank you.

First Name *
Last Name *
Date of Surgery *

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 pain	awful 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 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	Yes
Number
Yes, call me at home	Yes
Number
Yes, send me an email
No, please do not contact me	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 *
Today's Date *


* Required

Symptoms you are STILL experiencing: