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(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/Incisional 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 completely? 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 photograph (excluding face) showing hernia in standing & lying down position: Take picture from a distance of 4-5 feet. 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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1] Describe your hernia: (your)
LEFT, RIGHT or BOTH SIDES or OTHER? 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? 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? 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] Do you have
diabetes, taking any treatment?
20] Any other medical
condition or facts you think we should be aware of? You can start immediately by having the basic tests done in your own country to check if you are well enough to undergo the hernia repair surgical procedure. The tests are: 1. Haemogram 2. Routine urine test 3. Blood Sugar level (Fasting and Post lunch) 4. Blood Urea levels for kidney function 5. Hepatitis B test (Australia Antigen) 6. Test for HIV (AIDS test) 7. Chest X-Ray with report. 8. Ultrasound examination of abdomen & scrotum for inguinal hernia. 9. ECG and medical certificate of fitness from the physician 10. Bleeding & Clotting time
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