Tonsillectomy Outcomes Assessment Form
Please complete the Tonsillectomy Outcomes Assessment Form to help us evaluate your recovery and symptom progress after your tonsillectomy.
Full Name
*
First Name
Last Name
Date of Surgery
*
-
Month
-
Day
Year
Date
How would you rate your overall pain level in the past 24 hours?
*
1
2
3
4
5
6
7
8
9
10
How difficult has swallowing been since your surgery?
*
Not difficult at all
1
2
3
4
Extremely difficult
5
1 is Not difficult at all, 5 is Extremely difficult
Have you experienced any bleeding from your throat since surgery?
*
No
Yes, minor bleeding
Yes, significant bleeding
Have you had a fever (temperature above 100.4°F / 38°C) since your surgery?
*
No
Yes, once
Yes, more than once
Please rate your ability to eat solid foods since your surgery.
*
Unable to eat solids
1
2
3
4
Eating normally
5
1 is Unable to eat solids, 5 is Eating normally
How would you describe your sleep quality since the procedure?
*
Very poor
Poor
Average
Good
Excellent
Daily Symptom Tracker (Past 7 Days)
*
Rows
Pain Level (1-10)
Difficulty Swallowing (1-5)
Day 1
Day 2
Day 3
Day 4
Day 5
Day 6
Day 7
Please describe any other symptoms or concerns you have experienced.
Submit Assessment
Should be Empty: