Pre-Consultation Questionnaire

Name

First

Last

Height back hernia

Phone

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of birth

Where is your hernia?

Do you suffer from any of the following?

Height (Feet, Inches)

Weight (Lbs)

Is your current hernia a result of a previous surgery?

Is it close to an incision scar/line?

Is your current hernia on the right or left side or an umbilical?

Can you push your hernia back in (reducible)?

Is it a first time hernia or has it been operated on before?

If it's been operated on before, was prior surgery a mesh?

List any current medications:

Please share any other significant medical history

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