Patient Follow-Up & Survey

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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Follow-Up Evaluation