New Pilonidal Patient Questionnaire

If you are a new patient and live outside of the San Francisco Bay Area you should contact Dr. Sternberg prior to making an appointment. Please email a concise history of your story (with an emphasis on your pilonidal condition) well in advance of your trip to info@thesternbergclinic.com (see the instructions below).

Physical Exam: If you have any significant medical issues (e.g. Asthma, high blood pressure, heart issues, kidney issues, obesity, diabetes….) you should have a history and physical exam from your local primary doctor prior to traveling to San Francisco but within one month of your scheduled surgery. Dr. Sternberg’s office will assist your medical clearance if needed.

Download and Print the New Patient Questionnaire

Instructions for Patient History:

Here are the instructions for arranging your consultation and surgery if you live far away: Please make the history brief (bulleted points are best) and make sure to answer the following questions:

  • How old are you and what’s your date of birth?
  • Where do you live?
  • What’s your home address (should be the one associated with your insurance card)
  • What’s your cell phone and the cell phone number (and name, relationship) of your contact person who will be traveling with you?
  • Who is your pediatrician or primary care doctor (include address and phone number)?
  • If you’ve had surgery for pilonidal disease, who was your surgeon (address and phone number) and did your surgeon suggest that you contact me?
  • When did you first notice the condition (month, year)?
  • Have you required any office or emergency room drainage procedures, and how many?
  • Have you required operations in an operating room? How many, and when? If so, were the incisions closed or left open requiring packing?
  • How long did you require wound care?
  • Have you ever had a ‘Wound Vac’? For how long?
  • Very Important: have you been on more than one course of antibiotics in the last year for your pilonidal problem?  If yes, do you have an open or persistently draining wound? If yes, you will need to have a bacterial culture with sensitivities of the wound performed (within two months of your scheduled surgery) and sent to us at least two weeks before your trip.

Also include:

  • A list of any other operations you have had
  • Any medical conditions you have
  • A list of your medications
  • Any allergies you may have.
  • Your accurate height and weight.  No cheating, please.  Accuracy is essential as If your BMI is close to or greater than 40, It may influence which facility we can perform your surgery at.  Here’s a link to a BMI calculator.
  • A copy of the front and back of your Insurance Card

Please attach to the email 2 photos taken by someone who can see your bottom. Yes, another person: no cheating. It’s impossible for you to take adequate photos. For instructions on how to take the proper photos, please click here.

Send this to: info@thesternbergclinic.com

Patient Instructions and Forms

Download a New Patient History Form, and post-operative instructions for Pilonidal Surgery and General and Colorectal Surgery.

Download the Patient History Form

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

Appointment Hours

MonFriday: 9:00 am – 5:00 pm
Weekends: Closed

Featured in

The Sternberg Clinic Top Doctor

Member of ASCRS, Chron’s & Colitis Foundation,
American College of Surgeons, and Pilonidal Support Alliance

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