Postoperative Follow-up Form for Patients

Thank you for choosing SSM Health for your care. We are interested in how you have been feeling since your recent surgery. Your health and feedback are important to us. We greatly appreciate your response.

The Department of Surgery at SSM Health is a member of the American College of Surgeonsâ€™ National Surgical Quality Improvement Program. We are gathering information on the outcomes of our patients after surgery. Please take a few minutes to answer the questions below. All answers will remain confidential.

The required fields will be denoted by a RED Asterisk (only five fields)

First Name *

Last Name *

Date of Birth *

At which hospital did you have your surgery? *

SSM Health St. Mary's Hospital - Madison

SSM Health DePaul Hospital - St. Louis

SSM Health Saint Louis University Hospital

Have you been seen in an outpatient clinic or doctorâ€™s office since leaving the hospital from your surgery? *

Yes No

If yes, was this for a routine follow-up?

Yes No

If your visit was NOT for routine follow-up, what was the reason for your visit?

Date of that visit:

Have you experienced any of the following since leaving the hospital for your surgery?

Diagnosis of infection at incision site

Diagnosis of pneumonia

Diagnosis of new blood clot in arms or legs

Diagnosis of urinary tract infection (UTI)

Diagnosis of stool infection (C.Diff)

Diagnosis of pulmonary embolism (blood clot in lungs)

Heart attack

Stroke

Other (fill in below)

If you checked any of the above, please describe your symptoms and when they began:

Have you been back to the hospital or Emergency Department (ED) since your surgery?

Yes No

If yes, were you admitted?

Yes No

If yes, please explain reason for admission:

Date(s) of ED visit or hospitalization:

Did you have any additional surgery?

Yes No

If yes, please explain the type of surgery you had:

Date of additional surgery:

If you would like to provide more information via phone call, please leave a phone number for contact below:

Please use this box for any additional comments: