Pilonidal Disease: Pre-Op Health Survey - The Sternberg Clinic for Pilonidal Surgery

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.

Please complete this on a desktop computer. It is not formatted for a mobile device. Do not refresh your browser webpage or you will lose your input data. Your information is not captured or stored by The Sternberg Clinic.

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.

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

1 – Excellent

2 – Very good

3 – Good

4 – Fair

5 – Poor

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

1 – Much better now than one year ago

2 – Somewhat better now than one year ago

3 – About the same

4 – Somewhat worse now than one year ago

5 – Much worse now than one year ago

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?

	Yes, limited a lot	Yes, limited a little	No, not limited at all
3. Vigorous activities , such as running, lifting heavy objects, participating in strenuous sports	1	2	3
4. Moderate activities , such as moving a table, pushing a vacuum cleaner, bowling, or playing golf	1	2	3
5. Lifting or carrying groceries	1	2	3
6. Climbing several flights of stairs	1	2	3
7. Climbing one flight of stairs	1	2	3
8. Bending, kneeling, or stooping	1	2	3
9. Walking more than a mile	1	2	3
10. Walking several blocks	1	2	3
11. Walking one block	1	2	3
12. Bathing or dressing yourself	1	2	3

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 ?

	Yes	No
13. Cut down the amount of time you spent on work or other activities	1	2
14. Accomplished less than you would like	1	2
15. Were limited in the kind of work or other activities	1	2
16. Had difficulty performing the work or other activities (for example, it took extra effort)	1	2

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)?

	Yes	No
17. Cut down the amount of time you spent on work or other activities	1	2
18. Accomplished less than you would like	1	2
19. Didn’t do work or other activities as carefully as usual	1	2

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?

1 – Not at all

2 – Slightly

3 – Moderately

4 – Quite a bit

5 – Extremely

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

1 – None

2 – Very mild

3 – Mild

4 – Moderate

5 – Severe

6 – Very severe

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

1 – Not at all

2 – A little bit

3 – Moderately

4 – Quite a bit

5 – Extremely

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 …

	All of the time	Most of the time	A good bit of the time	Some of the time	A little of the time	None of the time
23. Did you feel full of pep?	1	2	3	4	5	6
24. Have you been a very nervous person?	1	2	3	4	5	6
25. Have you felt so down in the dumps that nothing could cheer you up?	1	2	3	4	5	6
26. Have you felt calm and peaceful?	1	2	3	4	5	6
27. Did you have a lot of energy?	1	2	3	4	5	6
28. Have you felt downhearted and blue?	1	2	3	4	5	6
29. Did you feel worn out?	1	2	3	4	5	6
30. Have you been a happy person?	1	2	3	4	5	6
31. Did you feel tired?	1	2	3	4	5	6

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.)?

1 – All of the time

2 – Most of the time

3 – Some of the time

4 – A little of the time

5 – None of the time

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

	Definitely true	Mostly true	Don’t know	Mostly false	Definitely false
33. I seem to get sick a little easier than other people	1	2	3	4	5
34. I am as healthy as anybody I know	1	2	3	4	5
35. I expect my health to get worse	1	2	3	4	5
36. My health is excellent	1	2	3	4	5

Print This Page as PDF

When you have completed this survey, click “Print this Page” above and save as a PDF on your computer desktop. Then simply email the PDF to info@thesternbergclinic.com.

Do not refresh your browser webpage or you will lose your input data. This pages is optimized for a desktop computer. Does not display on a mobile device.

Contact our San Francisco Office

To learn more about treating your Pilonidal Disease with surgery and the Cleft Lift procedure, contact our office staff for information or to schedule an appointment.

Did Dr. Sternberg treat your pilonidal disease? Submit a Patient Testimonial