Patient Follow-Up & Survey - Falls Church Healthcare Center

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© 2024 Falls Church Healthcare Center. Created for free using WordPress and Colibri

Patient Follow-Up

Online Follow-Up

Name*
First Last
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Today's Date
MM slash DD slash YYYY
Date of Birth*
Month
Day
Year
Phone*
May we leave a message?*
- Yes
- No
Email
Prefered Method of Contact:*
- Phone
- Email
Follow-Up Evaluation
Date of Procedure:*
MM slash DD slash YYYY
Tell us about your recovery:
What are the results of your at-home pregnancy test?*
- Not Pregnant
- Pregnant
How are you feeling now?*
Do you have any concerns?*
Tell us about your bleeding:
Number of days of bleeding*
Color of Bleeding*
- Red
- Pink
- Brown
- Mixture of All
Are you still bleeding?*
- Yes
- Just spotting
- No
Did you have clots?*
- Yes
- No
How often did you have clots?*
Size of clots*
Additional Questions:
Did you have any other vaginal discharge?*
- Yes
- No
Was there odor?*
- Yes
- No
Please describe further if needed:
Do you still have nausea?*
- Yes
- No
Do you still have breast tenderness?*
- Yes
- No
Did you start any hormonal birth control?*
- Yes
- No
When did you start hormonal birth control?*
MM slash DD slash YYYY
I would like a prescription for birth control
- I would like a prescription for birth control
Name of Pharmacy
Pharmacy Phone number
When was your last Well Woman Exam / Pap Smear test?
Can we help you with any GYN services or concerns?*
- Yes
- No
How can we help you?*
Have you had sexual intercourse since your procedure?*
- Yes
- No
Was protection used?*
- Yes
- No
Would you like us to call you to answer any further questions you may have?*
- Yes
- No
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© 2024 Falls Church Healthcare Center. Created for free using WordPress and Colibri

FCHC is closed December 24, 25, 30, and 31. Appointments are available for December 26, 27, 28, and 29.

Submit an appointment request now or call 703-532-2500 and we will respond when the Center re-opens.

Happy Holidays!

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