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



1] Describe where your hernia is, including if it is on (your) LEFT, RIGHT or BOTH SIDES or MIDLINE?

 

2] Does it extend into the scrotum?

 

3] Can you feel a bulge in the area concerned- visible or not - perhaps when you cough?

 

4] How large is your hernia? Choose from the list?

 

5] Does it go - or can you push it - back in completely?

 

6] Does this hernia give Pain or Discomfort?

 

7] How long have you had this hernia?

 

8] Has this hernia ever been repaired before?

 

9] Have you ever had any serious illness or operations before?

 

10] Is this hernia in the area of the scar from a previous operation?

 

11] Have you ever had heart problems or breathing problems?

 

12] Have you ever had blood pressure (high OR low) problems?

 

13] Have you ever had breathing or chest problems?

 

14] Do you have any urinary problems ('passing water')?

 

15] Are you taking medication for anything?

 

16] Are you taking aspirin regularly?

 

17] Are you taking anticoagulants?

 

18] Are you allergic to any medication?

 

19] Any other medical condition or facts you think we should be aware of?

 

20] Do you have health insurance?




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