Post-Procedure Waiting Period Check-In Form
Please complete this check-in form to help us monitor your comfort and well-being during the post-procedure waiting period.
Full Name
*
First Name
Last Name
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Time of Check-In
*
Hour Minutes
AM
PM
AM/PM Option
Procedure Type
*
Please Select
Minor outpatient
Day surgery
Diagnostic
Other
Are you experiencing any discomfort?
*
No discomfort
Mild discomfort
Moderate discomfort
Severe discomfort
Please rate your current pain level
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst possible pain
10
0 is No pain, 10 is Worst possible pain
Are you experiencing any of the following symptoms?
*
Nausea
Dizziness
Fatigue
Chills
None of these
Other
How would you describe your overall well-being right now?
*
Excellent
Good
Fair
Poor
Do you need any immediate assistance?
*
No
Yes, please check on me
Additional comments or requests
Submit Check-In
Should be Empty: