QUESTIONNAIRE of a patient who underwent endovideosurgical hernioplasty for inguinal hernia
Dear patient! You underwent high-tech surgery for an inguinal hernia. In order to improve the efficiency of the surgical service of our medical institution, we ask you to answer a few questions. Send your answer by mail in the envelope attached to this letter. Thank you.
1. Surname, name, patronymic ____________________________________________
2. Gender: male female (circle as appropriate)
3. Age________
4. Date of operation________________
5. Type of hernioplasty____________________________ (not filled in by the patient)
6. Implant fixation method_________________________ (not filled in by the patient)
7. Duration of temporary disability after surgery (for employees), days: (circle as appropriate)
Up to 7				8–14		15–21		over 21
8. Time to return to physical activity after surgery: (circle as appropriate)
1–2 weeks				3–4 weeks		5–6 weeks		more than 6 weeks
9. Do you have any pain in the area of the operation at the moment? (circle as appropriate)
YES						NO
10. If YES, then rate their intensity on a 10-point system, where 0-no pain, 10-unbearable pain: (circle as appropriate)
0	1	2	3	4	5	6	7	8	9	10
10.1. Have you taken any pain medication for this pain? (circle as appropriate)
Daily (2–3 times a day)						Daily (1 time a day)
Periodically				Rarely				Very rarely
11. Are you satisfied with the result of the operation? (circle as appropriate)
YES (Completely)				YES (Partially)		NO
12. Did the hernia appear again in the same place? (circle as appropriate)
YES						NO