Hernia Surgery Follow-up Form
Please complete this form to help us evaluate your recovery after hernia surgery.
Full Name
*
First Name
Last Name
Date of Surgery
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
How would you rate your current pain or discomfort?
*
1
2
3
4
5
Do you notice any swelling, redness, or discharge at the surgical site?
*
No
Mild
Moderate
Severe
Are you able to perform your usual daily activities?
*
Yes, without difficulty
Yes, but with some difficulty
No, unable to perform usual activities
Have you experienced any of the following since your surgery?
*
Fever
Increased pain
Bleeding
Nausea or vomiting
None of the above
Are you taking your prescribed medications as directed?
*
Yes, all medications as directed
Some medications missed
Not taking prescribed medications
How satisfied are you with your recovery progress?
*
1
2
3
4
5
Would you like a follow-up appointment or call?
Yes, please contact me
No, not needed at this time
Additional comments or concerns
Submit
Should be Empty: