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.
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 email@example.com
Do not refresh your browser webpage or you will lose your input data.