New Pilonidal Patient Questionnaire

If you are a new patient and live outside of the San Francisco Bay Area, please fill out the form below and email it to our staff at the Sternberg Clinic Sternberg info@thesternbergclinic.com prior to making an appointment with Dr. Jeffrey Sternberg. This will provide our team with a concise history of your Pilonidal Disease story. Sending this well in advance of your visit gives our team adequate time to understand your case and make the most of your visit to our San Francisco medical clinic.

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:

Personal Information and Contact Information:

  • How Old Are You?
  • Date of birth
  • Home Address (associated with your insurance card):
  • Cell Phone Number
  • Email Address
  • Your Travel Companion’s Name and Relationship and Cell Phone Number
  • Primary Care Physician or Pediatrician, Name, Address, and Phone Number.

Questions about your pilonidal problem:

  • When did you first notice the condition?
  • Have you required any office or emergency room drainage procedures?  
  • If, “Yes” how many times?
  • Has your Pilonidal Disease required operations in an operating room? 
  • If, “Yes” how many times?
  • Please List any past Pilonidal operations.
  • Did you find us on your own?
  • What search terms did you use?
  • Did someone refer you to the Sternberg Clinic?
  • Have you required wound care? Y/N For how long?
  • Have you ever had a ‘Wound Vac’? If yes, For how long?

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 may 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.  We will let you know.

Additional Medical Information:

  • Please list any medical conditions you have.
  • Please list any other operations you have had unrelated to your Pilonidal Disease.
  • Please list any medications that you take regularly.
  • Please list any allergies you may have.

Please list your accurate height and weight: No cheating, please.  Accuracy is essential.  If you’re your BMI is close to or greater than 40 you will be required to lose weight prior to travel for surgery.  Here’s a link to a BMI calculator.

In addition to this information, please include a photo of the front and back of your Insurance Card 

Also include TWO PHOTOS of your bottom taken by someone who can see your Pilonidal Disease wound clearly. (Yes, another person: no cheating.) It’s impossible for you to take adequate photos on your own. For instructions on how to take the proper photos please click here.

Please email this form to info@thesternbergclinic.com.  In the subject line please include your name and the words “new patient inquiry”.  Our email is HIPAA-compliant.

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, Crohn’s & Colitis Foundation,
American College of Surgeons, and Pilonidal Support Alliance

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