Surgery Recovery Assessment
Please complete this assessment to help your healthcare provider monitor your recovery after surgery.
Patient Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Contact Email Address
*
example@example.com
Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Surgery
*
Please Select
Orthopedic
Cardiac
Abdominal
Neurological
ENT (Ear, Nose, Throat)
Other
Please rate the following aspects of your recovery over the past 3 days:
*
Rows
None
Mild
Moderate
Severe
Pain at surgical site
1
2
3
4
Swelling or redness
5
6
7
8
Fever
9
10
11
12
Nausea or vomiting
13
14
15
16
Difficulty moving
17
18
19
20
How would you rate your overall pain level today?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst imaginable pain
10
0 is No pain, 10 is Worst imaginable pain
Are you able to perform your daily activities (e.g., walking, dressing, eating) as usual?
*
Yes, without difficulty
Yes, with some difficulty
No, I need assistance
Have you noticed any of the following at your surgical site? (Select all that apply)
*
Increased redness or swelling
Unusual discharge or pus
Opening of the wound
No concerning changes
Other
Are you taking your prescribed medications as directed?
*
Yes, all medications as prescribed
Missed some doses
Stopped taking medications
Do you have any additional concerns or symptoms you'd like to report?
Signature (please sign to confirm your responses)
*
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