Hernia Form


 
(Copy this form, fill in and then send it to us by email)

DESARDA HERNIA CENTER QUESTIONNAIRE
(Please complete this questionnaire in full. This information will assist us in your care plan. All questions contained in this questionnaire are strictly confidential and will become part of your medical record. For patients living at a distance, this questionnaire is designed to help facilitate your examination, admission, and surgery in one visit. However, an in-person physical examination at our clinic is required to make a final diagnosis and a treatment plan.) Pl. strike through or delete whichever is not applicable & keep the desired.

DATE: 

Name (Last, First, M):                                                                                                  Sex:    M      F           AGE:         Years

Address:  City, State, Country: 

Phone:

Email:  

PERSONAL HEALTH HISTORY 

1] Height:                (Inches)    2] Weight:               (Kg)      3] BUILT:   Obese / Avg / Thin 

4] Waist at the navel (inches):                                    Chest, not expanded (inches):

5] Hernia Type: Inguinal (Groin one side or both sides)/ Umbilical/ Epigastric/ Spigelian/ Ventral Hernia

6] Is this your first groin hernia?             Yes  No          

7] Previous repairs?     Yes    No       Which type?  Open/ Laparoscopic  AND with/without mesh

8] Can you reduce (push back in) your hernia?     Yes      No          

9] Size of hernia:  Walnut/   Egg/    Grapefruit/   Enters Scrotal bag (Yes / No)        

10] Has the hernia(s) identified by a medical doctor or Ultra sound ?    Yes      No

11] Give us detailed history: of major illness/ heart attack/ breathing problems/ allergy/ any treatment etc.

12] Attach (if possible/agreed to) a full height photograph (excluding face) showing hernia in standing & lying

      Down position: This gives us a clear picture of hernia & body to plan your hernia surgery in a better way.

      Pictures shown below are as an example. Delete them and paste your pictures. You may paste more pictures.


Paste a photo in standing position showing   visible hernia

 

Paste a photo in lying down position showing reduced hernia





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