POST-OPERATIVE FOLLOW-UP

CEC POST-OPERATIVE DATA COLLECTION SURVEY

If you are a CEC patient who is at least 6 months post-operative (preferably 12+ months), please assist us by completing the following data input. We appreciate the time you will spend providing this information. Should you need assistance, please call 770-913-0001 x120. Please be advised this is a HIPAA-enabled platform and your feedback is never shared outside the Center. Many thanks! - Center for Endometriosis Care

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* 1. PLEASE ENTER TODAY'S DATE:

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* 2. PATIENT NAME:

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* 3. IF YOUR NAME WAS DIFFERENT AT THE TIME OF SURGERY, PLEASE INDICATE THE NAME ON FILE WITH US:

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* 4. DATE OF BIRTH:

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* 5. DATE OF CEC SURGERY (IF MORE THAN ONE, LIST ONLY MOST RECENT):

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* 6. NAME OF CEC SURGEON:

Dr Ken Sinervo

Dr Jose Eugenio-Colon

If neither of the above, please enter the name of the Surgeon who performed your procedures during their time at the CEC.

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* 7. CURRENT CONTACT INFORMATION (MAIL, PHONE, EMAIL):

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Country

Email Address

Phone Number

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* 8. IF YOU HAVE NOT ALREADY PREVIOUSLY CONTACTED US TO FOLLOW-UP ON ANY AREAS OF CONCERN, DO YOU WISH TO BE CONTACTED REGARDING THE FEEDBACK YOU ARE PROVIDING?

Yes

If yes, please enter your preferred method of contact (phone or email):

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* 9. DID YOU HAVE ANY POST-OPERATIVE COMPLICATIONS WE WERE NOT ALREADY AWARE OF?

Yes

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* 10. IF YES, PLEASE LIST DIAGNOSES AND TREATMENTS UNDERTAKEN.

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* 11. SINCE YOUR SURGERY WITH US, HAS ANOTHER PHYSICIAN PRESCRIBED ANY SUPPRESSIVE MEDICATIONS INCLUDING BUT NOT LIMITED TO ORILISSA®, LUPRON®, SYNAREL®, ZOLADEX®, VISANNE®, FEMARA®, DEPO PROVERA®, MIRENA® OR OTHER?

Yes

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* 12. IF YES, PLEASE LIST DRUG(S) AND INDICATIONS FOR USE.

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* 13. SINCE YOUR CEC SURGERY, HAVE YOU HAD ANOTHER PELVIC SURGERY FOR PAIN, INFERTILITY, OR OTHER REASON WITH ANOTHER PHYSICIAN?

Yes

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* 14. IF YES, PLEASE LIST ANY SURGERIES AND THE INDICATIONS FOR WHICH THE PROCEDURES WERE PERFORMED:

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* 15. WAS ENDOMETRIOSIS CONFIRMED VIA BIOPSY IN ANY SUBSEQUENT PELVIC SURGERY?

Yes

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* 16. IF YES TO ABOVE, PLEASE PROVIDE US WITH A COPY OF THE OPERATIVE AND PATHOLOGY REPORT. THANK YOU.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 17. HAVE YOU UNDERGONE ANY IMAGING/BIOMARKER/OTHER STUDIES IN WHICH ENDOMETRIOSIS WAS SUSPECTED?

Yes

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* 18. IF YES, PLEASE UPLOAD THE IMAGING/TEST RESULTS HERE.

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.

Choose File

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* 19. SINCE YOUR CEC SURGERY, HAVE YOU TRIED TO CONCEIVE?

Yes

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* 20. IF YES, PLEASE INDICATE IF YOU CONCEIVED NATURALLY/VIA ART OR IVF/OTHER/DESCRIBE.

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* 21. IF YES, DID YOU EXPERIENCE ANY OBSTETRICAL COMPLICATIONS? PLEASE DESCRIBE.

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* 22. IF YES, PLEASE TELL US THE OUTCOME OF ANY PREGNANCIES.

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* 23. PLEASE RATE YOUR QUALITY OF LIFE AS YOU ARE EXPERIENCING IT NOW, PARTICULARLY AS RELATED TO ANY PELVIC OR ABDOMINAL PAIN.

AWFUL

POOR

FAIR

GOOD

TERRIFIC

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* 24. SYMPTOMS YOU ARE STILL EXPERIENCING (check all that apply; slight=does not require pain medication; moderate=requires non-narcotic pain medication; severe=requires narcotic pain medication; crippling=keeps you from performing daily tasks):

	Slight	Moderate	Severe	Crippling
PELVIC PAIN/CRAMPING (NON-MENSTRUAL)	PELVIC PAIN/CRAMPING (NON-MENSTRUAL) Slight	PELVIC PAIN/CRAMPING (NON-MENSTRUAL) Moderate	PELVIC PAIN/CRAMPING (NON-MENSTRUAL) Severe	PELVIC PAIN/CRAMPING (NON-MENSTRUAL) Crippling
MENSTRUAL CRAMPS	MENSTRUAL CRAMPS Slight	MENSTRUAL CRAMPS Moderate	MENSTRUAL CRAMPS Severe	MENSTRUAL CRAMPS Crippling
PAINFUL SEX	PAINFUL SEX Slight	PAINFUL SEX Moderate	PAINFUL SEX Severe	PAINFUL SEX Crippling
PAINFUL BOWEL MOVEMENTS	PAINFUL BOWEL MOVEMENTS Slight	PAINFUL BOWEL MOVEMENTS Moderate	PAINFUL BOWEL MOVEMENTS Severe	PAINFUL BOWEL MOVEMENTS Crippling
CONSTIPATION	CONSTIPATION Slight	CONSTIPATION Moderate	CONSTIPATION Severe	CONSTIPATION Crippling
DIARRHEA	DIARRHEA Slight	DIARRHEA Moderate	DIARRHEA Severe	DIARRHEA Crippling
INTESTINAL CRAMPING	INTESTINAL CRAMPING Slight	INTESTINAL CRAMPING Moderate	INTESTINAL CRAMPING Severe	INTESTINAL CRAMPING Crippling
ABDOMINAL PAIN	ABDOMINAL PAIN Slight	ABDOMINAL PAIN Moderate	ABDOMINAL PAIN Severe	ABDOMINAL PAIN Crippling
BLADDER PAIN	BLADDER PAIN Slight	BLADDER PAIN Moderate	BLADDER PAIN Severe	BLADDER PAIN Crippling
KIDNEY/FLANK PAIN	KIDNEY/FLANK PAIN Slight	KIDNEY/FLANK PAIN Moderate	KIDNEY/FLANK PAIN Severe	KIDNEY/FLANK PAIN Crippling
PELVIC PAIN WITH EXERCISE	PELVIC PAIN WITH EXERCISE Slight	PELVIC PAIN WITH EXERCISE Moderate	PELVIC PAIN WITH EXERCISE Severe	PELVIC PAIN WITH EXERCISE Crippling
BACK ACHE	BACK ACHE Slight	BACK ACHE Moderate	BACK ACHE Severe	BACK ACHE Crippling
LEG ACHE	LEG ACHE Slight	LEG ACHE Moderate	LEG ACHE Severe	LEG ACHE Crippling
RECURRENT PNEUMOTHORAX/COUGHING UP BLOOD/LUNG PAIN	RECURRENT PNEUMOTHORAX/COUGHING UP BLOOD/LUNG PAIN Slight	RECURRENT PNEUMOTHORAX/COUGHING UP BLOOD/LUNG PAIN Moderate	RECURRENT PNEUMOTHORAX/COUGHING UP BLOOD/LUNG PAIN Severe	RECURRENT PNEUMOTHORAX/COUGHING UP BLOOD/LUNG PAIN Crippling
PAINFUL PELVIC EXAM	PAINFUL PELVIC EXAM Slight	PAINFUL PELVIC EXAM Moderate	PAINFUL PELVIC EXAM Severe	PAINFUL PELVIC EXAM Crippling

Other (please specify)

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* 25. WHAT, IF ANY, NON-SURGICAL TREATMENTS HAVE YOU TRIED/ARE YOU UNDERGOING FOR YOUR CONTINUING PAIN/SYMPTOMS? CHECK ALL THAT APPLY.

Pelvic Floor Physical Therapy

Pain Management

Cognitive-behavioral Therapy Protocols for Patients with Pain

Nutritional Intervention

Other - please describe in detail

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* 26. ARE YOU UNDER THE CARE OF A PHYSICIAN, PHYSICAL THERAPIST OR OTHER HEALTHCARE PROVIDER?

Yes

POST-OPERATIVE FOLLOW-UP

CEC POST-OPERATIVE DATA COLLECTION SURVEY

Question Title

* 1. PLEASE ENTER TODAY'S DATE:

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* 2. PATIENT NAME:

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* 3. IF YOUR NAME WAS DIFFERENT AT THE TIME OF SURGERY, PLEASE INDICATE THE NAME ON FILE WITH US:

Question Title

* 4. DATE OF BIRTH:

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* 5. DATE OF CEC SURGERY (IF MORE THAN ONE, LIST ONLY MOST RECENT):

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* 6. NAME OF CEC SURGEON:

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* 7. CURRENT CONTACT INFORMATION (MAIL, PHONE, EMAIL):

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* 8. IF YOU HAVE NOT ALREADY PREVIOUSLY CONTACTED US TO FOLLOW-UP ON ANY AREAS OF CONCERN, DO YOU WISH TO BE CONTACTED REGARDING THE FEEDBACK YOU ARE PROVIDING?

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* 9. DID YOU HAVE ANY POST-OPERATIVE COMPLICATIONS WE WERE NOT ALREADY AWARE OF?

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* 10. IF YES, PLEASE LIST DIAGNOSES AND TREATMENTS UNDERTAKEN.

Question Title

* 11. SINCE YOUR SURGERY WITH US, HAS ANOTHER PHYSICIAN PRESCRIBED ANY SUPPRESSIVE MEDICATIONS INCLUDING BUT NOT LIMITED TO ORILISSA®, LUPRON®, SYNAREL®, ZOLADEX®, VISANNE®, FEMARA®, DEPO PROVERA®, MIRENA® OR OTHER?

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* 12. IF YES, PLEASE LIST DRUG(S) AND INDICATIONS FOR USE.

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* 13. SINCE YOUR CEC SURGERY, HAVE YOU HAD ANOTHER PELVIC SURGERY FOR PAIN, INFERTILITY, OR OTHER REASON WITH ANOTHER PHYSICIAN?

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* 14. IF YES, PLEASE LIST ANY SURGERIES AND THE INDICATIONS FOR WHICH THE PROCEDURES WERE PERFORMED:

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* 15. WAS ENDOMETRIOSIS CONFIRMED VIA BIOPSY IN ANY SUBSEQUENT PELVIC SURGERY?

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* 16. IF YES TO ABOVE, PLEASE PROVIDE US WITH A COPY OF THE OPERATIVE AND PATHOLOGY REPORT. THANK YOU.

Question Title

* 17. HAVE YOU UNDERGONE ANY IMAGING/BIOMARKER/OTHER STUDIES IN WHICH ENDOMETRIOSIS WAS SUSPECTED?

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* 18. IF YES, PLEASE UPLOAD THE IMAGING/TEST RESULTS HERE.

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* 19. SINCE YOUR CEC SURGERY, HAVE YOU TRIED TO CONCEIVE?

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* 20. IF YES, PLEASE INDICATE IF YOU CONCEIVED NATURALLY/VIA ART OR IVF/OTHER/DESCRIBE.

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* 21. IF YES, DID YOU EXPERIENCE ANY OBSTETRICAL COMPLICATIONS? PLEASE DESCRIBE.

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* 22. IF YES, PLEASE TELL US THE OUTCOME OF ANY PREGNANCIES.

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* 23. PLEASE RATE YOUR QUALITY OF LIFE AS YOU ARE EXPERIENCING IT NOW, PARTICULARLY AS RELATED TO ANY PELVIC OR ABDOMINAL PAIN.

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* 24. SYMPTOMS YOU ARE STILL EXPERIENCING (check all that apply; slight=does not require pain medication; moderate=requires non-narcotic pain medication; severe=requires narcotic pain medication; crippling=keeps you from performing daily tasks):

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* 25. WHAT, IF ANY, NON-SURGICAL TREATMENTS HAVE YOU TRIED/ARE YOU UNDERGOING FOR YOUR CONTINUING PAIN/SYMPTOMS? CHECK ALL THAT APPLY.

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* 26. ARE YOU UNDER THE CARE OF A PHYSICIAN, PHYSICAL THERAPIST OR OTHER HEALTHCARE PROVIDER?

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* 27. IF YES, PLEASE LIST CURRENT TYPE(S) OF PROVIDERS (MD, PT, PAIN MANAGEMENT, ETC.)

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* 28. IS THERE ANYTHING ELSE YOU WOULD LIKE US TO KNOW?