Surgical Site Infection Survey
Help us assess and improve surgical care by providing information about your recent surgery and any signs of infection.
Patient Full Name
*
First Name
Last Name
Patient Age
*
Gender
*
Male
Female
Other
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Type of Surgery
*
Please Select
Orthopedic
Cardiac
Abdominal
Gynecological
Neurosurgery
Other
Have you experienced any signs of infection at your surgical site?
*
Yes
No
If yes, please indicate which symptoms you have experienced:
Redness
Swelling
Pain or tenderness
Warmth at site
Pus or discharge
Fever
Other
Please rate the severity of your symptoms:
1
2
3
4
5
Wound Assessment
Rows
Present
Absent
Redness
1
2
Swelling
3
4
Discharge
5
6
Dehiscence (wound opening)
7
8
Have you received antibiotics for your surgical site since your surgery?
Yes
No
Do you have any of the following risk factors?
Diabetes
Obesity
Smoking
Immunosuppression
Chronic illness
None of the above
Overall, how satisfied are you with the care you received?
Not Satisfied
1
2
3
4
Very Satisfied
5
1 is Not Satisfied, 5 is Very Satisfied
Additional Comments or Feedback
Submit Survey
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