Hernia Surgery Pre-Op QPROM

Thank you for choosing Kinvara Private Hospital for your hernia surgery. Please complete this short questionnaire (known as a Quality Patient-Reported Outcome Measure – QPROM).

The questionnaire should only be completed by patients who due to have hernia surgery and will only take a few minutes.

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Name
Date of birth
1. Is anyone helping you fill in this questionnaire?
2. Are you?
3. Which statement best describes your living arrangements?
4. How long have you had symptoms of a hernia?
5. Have you had a previous hernia operation on the side on which you are about to have surgery?
6. Mobility
7. Self-care
8. Usual activities (e.g. work, study, housework, family)
9. Pain / discomfort
10. Anxiety / depression
11. In general, how would you rate your general health?
12. Have you been told by a doctor that you have any of the following? (Check all that apply)
13. Do you consider yourself to have a disability?