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 Surgeons’ 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)

SSM Health St. Mary's Hospital - Madison
SSM Health DePaul Hospital - St. Louis
SSM Health Saint Louis University Hospital
Yes No
Yes No
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
Other (fill in below)
Yes No
Yes No
Yes No