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Hernia Screening Questionnaire
Hernia Screening Questionnaire
St. Elizabeth Website Coordinator
2025-06-27T16:37:45-04:00
Hernia Screening Questionnaire
Welcome to St. Elizabeth's hernia screening questionnaire. We're here to help you take the first step toward understanding your health. This quick and easy quiz is designed to give you valuable insights and guide you toward the best care options available. By answering a few simple questions, you can gain a clearer picture of your symptoms and take proactive steps toward your well-being. Ready to get started? Take the quiz now and embark on your journey to better health.
Do you notice a bulge in the groin?
(Required)
Yes
No
Does the bulge get larger/become more noticeable later in the day?
(Required)
Yes
No
Do you have pain in the groin area?
(Required)
Yes
No
Does activity or being on your feet make the pain/soreness worse?
(Required)
Yes
No
Do you ever feel or hear gurgling in the groin?
(Required)
Yes
No
Do you notice a bulge or "outtie" at the belly button?
(Required)
Yes
No
Does the bulge get larger/become more noticeable later in the day?
(Required)
Yes
No
Do you have pain in the belly button area?
(Required)
Yes
No
Does activity or being on your feet make the pain/soreness worse?
(Required)
Yes
No
Do you ever feel or hear gurgling in the belly button?
(Required)
Yes
No
Have you had prior abdominal surgery?
(Required)
Yes
No
Do you notice a bulge at any of the scars from your prior incisions?
(Required)
Yes
No
Do you have any pain at the scars from your prior incisions?
(Required)
Yes
No
Does activity, lifting, or being on your feet make the pain/soreness worse?
(Required)
Yes
No
Do you ever feel or hear gurgling at the scars from your prior incisions?
(Required)
Yes
No
Do you have chronic constipation or have to strain to move your bowels or empty your bladder?
(Required)
Yes
No
Do you have a chronic or recurrent cough?
(Required)
Yes
No
Name
(Required)
First
Last
Primary Language
Phone
(Required)
Zip or Postal Code
(Required)
Your Email Address
(Required)
Preferred Contact Time
(Required)
Anytime
Morning (8 a.m. - noon)
Afternoon (noon - 4 p.m.)
Evening (4 p.m. - 7 p.m.)
Preferred Provider
Preferred Location
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Consent
(Required)
By using this website and submitting this form, I agree to the terms of the privacy policy and terms of use. I consent to receive follow up communication from St. Elizabeth Healthcare by phone and email related to this service.
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