Skip to content

POST-OPERATIVE FOLLOW-UP

CEC POST-OPERATIVE DATA COLLECTION SURVEY

If you are a CEC patient who is at least 6 months post-operative (preferably 12+ months), please assist us by completing the following data input. We appreciate the time you will spend providing this information. Should you need assistance, please call 770-913-0001 x120. Please be advised this is a HIPAA-enabled platform and your feedback is never shared outside the Center. Many thanks! - Center for Endometriosis Care
1.PLEASE ENTER TODAY'S DATE:
2.PATIENT NAME:
3.IF YOUR NAME WAS DIFFERENT AT THE TIME OF SURGERY, PLEASE INDICATE THE NAME ON FILE WITH US:
4.DATE OF BIRTH:
5.DATE OF CEC SURGERY (IF MORE THAN ONE, LIST ONLY MOST RECENT):
6.NAME OF CEC SURGEON:
7.CURRENT CONTACT INFORMATION (MAIL, PHONE, EMAIL):
8.IF YOU HAVE NOT ALREADY PREVIOUSLY CONTACTED US TO FOLLOW-UP ON ANY AREAS OF CONCERN, DO YOU WISH TO BE CONTACTED REGARDING THE FEEDBACK YOU ARE PROVIDING?
9.DID YOU HAVE ANY POST-OPERATIVE COMPLICATIONS WE WERE NOT ALREADY AWARE OF?
10.IF YES, PLEASE LIST DIAGNOSES AND TREATMENTS UNDERTAKEN.
11.SINCE YOUR SURGERY WITH US, HAS ANOTHER PHYSICIAN PRESCRIBED ANY SUPPRESSIVE MEDICATIONS INCLUDING BUT NOT LIMITED TO ORILISSA®, LUPRON®, SYNAREL®, ZOLADEX®, VISANNE®, FEMARA®, DEPO PROVERA®, MIRENA® OR OTHER?
12.IF YES, PLEASE LIST DRUG(S) AND INDICATIONS FOR USE.
13.SINCE YOUR CEC SURGERY, HAVE YOU HAD ANOTHER PELVIC SURGERY FOR PAIN, INFERTILITY, OR OTHER REASON WITH ANOTHER PHYSICIAN?
14.IF YES,  PLEASE LIST ANY SURGERIES AND THE INDICATIONS FOR WHICH THE PROCEDURES WERE PERFORMED:
15.WAS ENDOMETRIOSIS CONFIRMED VIA BIOPSY IN ANY SUBSEQUENT PELVIC SURGERY?
16.IF YES TO ABOVE, PLEASE PROVIDE US WITH A COPY OF THE OPERATIVE AND PATHOLOGY REPORT. THANK YOU.
No file chosen
17.HAVE YOU UNDERGONE ANY IMAGING/BIOMARKER/OTHER STUDIES IN WHICH ENDOMETRIOSIS WAS SUSPECTED?
18.IF YES, PLEASE UPLOAD THE IMAGING/TEST RESULTS HERE.
No file chosen
19.SINCE YOUR CEC SURGERY, HAVE YOU TRIED TO CONCEIVE?
20.IF YES, PLEASE INDICATE IF YOU CONCEIVED NATURALLY/VIA ART OR IVF/OTHER/DESCRIBE.
21.IF YES, DID YOU EXPERIENCE ANY OBSTETRICAL COMPLICATIONS? PLEASE DESCRIBE.
22.IF YES, PLEASE TELL US THE OUTCOME OF ANY PREGNANCIES.
23.PLEASE RATE YOUR QUALITY OF LIFE AS YOU ARE EXPERIENCING IT NOW, PARTICULARLY AS RELATED TO ANY PELVIC OR ABDOMINAL PAIN.
24.SYMPTOMS YOU ARE STILL EXPERIENCING (check all that apply; slight=does not require pain medication; moderate=requires non-narcotic pain medication; severe=requires narcotic pain medication; crippling=keeps you from performing daily tasks):
Slight
Moderate
Severe
Crippling
PELVIC PAIN/CRAMPING (NON-MENSTRUAL)
MENSTRUAL CRAMPS
PAINFUL SEX
PAINFUL BOWEL MOVEMENTS
CONSTIPATION
DIARRHEA
INTESTINAL CRAMPING
ABDOMINAL PAIN
BLADDER PAIN
KIDNEY/FLANK PAIN
PELVIC PAIN WITH EXERCISE
BACK  ACHE
LEG ACHE
RECURRENT PNEUMOTHORAX/COUGHING UP BLOOD/LUNG PAIN
PAINFUL PELVIC EXAM
25.WHAT, IF ANY, NON-SURGICAL TREATMENTS HAVE YOU TRIED/ARE YOU UNDERGOING FOR YOUR CONTINUING PAIN/SYMPTOMS? CHECK ALL THAT APPLY.
26.ARE YOU UNDER THE CARE OF A PHYSICIAN, PHYSICAL THERAPIST OR OTHER HEALTHCARE PROVIDER?
27.IF YES, PLEASE LIST CURRENT TYPE(S) OF PROVIDERS (MD, PT, PAIN MANAGEMENT, ETC.)
28.IS THERE ANYTHING ELSE YOU WOULD LIKE US TO KNOW?
Privacy & Cookie Notice