Pilonidal Disease: Pre-Op Health Survey

Please answer the 37 questions of the health survey completely, honestly, and without interruptions with regards to how your (or your child’s) pilonidal condition is affecting you or them.

Choose one option for each questionnaire item. When you are done, click the button to “Print Completed Form” and save as a PDF or print on paper. Please complete prior to your day of surgery.

Do not refresh your browser webpage or you will lose your input data. Your information is not captured or stored by The Sternberg Clinic.

1. In general, would you say your health as affected by your pilonidal condition is:

2. Compared to one year ago , how would you rate your health in general now as you live with a pilonidal condition?

The following items are about activities you might do during a typical day. Does your pilonidal condition now limit you in these activities? If so, how much?

 

3. Vigorous activities , such as running, lifting heavy objects, participating in strenuous sports

4. Moderate activities , such as moving a table, pushing a vacuum cleaner, bowling, or playing golf

5. Lifting or carrying groceries

6. Climbing several flights of stairs

7. Climbing one flight of stairs

8. Bending, kneeling, or stooping

9. Walking more than a mile

10. Walking several blocks

11. Walking one block

12. Bathing or dressing yourself

During the past 4 weeks , have you had any of the following problems with your work or other regular daily activities as a result of your pilonidal condition ?

 

13. Cut down the amount of time you spent on work or other activities

14. Accomplished less than you would like

15. Were limited in the kind of work or other activities

16. Had difficulty performing the work or other activities (for example, it took extra effort)

During the past 4 weeks , have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

 

17. Cut down the amount of time you spent on work or other activities

18. Accomplished less than you would like

19. Didn’t do work or other activities as carefully as usual

20. During the past 4 weeks , to what extent has your physical health or emotional problems interfered with your normal social activities with family, friends, neighbors, or groups?

21. How much bodily pain have you had during the past 4 weeks ?

22. During the past 4 weeks , how much did pain interfere with your normal work (including both work outside the home and housework)?

These questions are about how you feel and how things have been with you during the past 4 weeks . For each question, please give the one answer that comes closest to the way you have been feeling.

How much of the time during the past 4 weeks

 

23. Did you feel full of pep?

24. Have you been a very nervous person?

25. Have you felt so down in the dumps that nothing could cheer you up?

26. Have you felt calm and peaceful?

27. Did you have a lot of energy?

28. Have you felt downhearted and blue?

29. Did you feel worn out?

30. Have you been a happy person?

31. Did you feel tired?

32. During the past 4 weeks , how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

How TRUE or FALSE is each of the following statements for you.

 

33. I seem to get sick a little easier than other people

34. I am as healthy as anybody I know

35. I expect my health to get worse

36. My health is excellent

Print This Page

When you have completed this survey, click “Print this Page” above. Send your completed form, along with your Patient ID Number, to info@thesternbergclinic.com

Do not refresh your browser webpage or you will lose your input data.

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