Suggested Data Collection Forms (Page 4 of 4) in pdf

Suggested Data Collection Forms Page 4

FOLLOW-UP HYPERHIDROSIS SURVEY (administered 1 month, 6 month, and yearly after surgery)

Name: _________________________________Date: ________________________

Months postoperative: _____________Hospital/surgeon: __________________________

Postoperative pain score 0 (no pain) to 10 (extreme pain requiring narcotics): _______________

Compensatory hyperhidrosis? AbsentLight Moderate Intense

If present, location(s) of CH:Stomach Back Groin Buttocks Legs Other: _______

Situation when CH present: Always Heat Physical activity Stress

Did your symptoms reoccur? ( ) No ( ) Yes, when, where? ______________________________

Overall satisfaction with the procedure?

( ) 100% (Very good) ( ) 90% (Good) ( ) 75% (Regular) ( )

50% (Bad)

Gustatory sweating: ( ) No ( ) Yes When: ___________________________________

Scar aesthetic results: ( ) Very good ( ) Good ( ) Regular ( ) Bad

Did you have to seek additional treatment after surgery (or have to have another surgery)?

Which one?

Would you have this surgery again, if you were able to go back in time and redo? ( ) Yes

( ) No

Would you recommend this surgery to a friend who had the similar condition? ( ) Yes

( ) No

Suggested Data Collection Forms Page 4