Pilonidal Patient Medical History Form - Evergreen Surgical Pilonidal Clinic

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Patient Name

Gender

Address

Address Line 1

Address Line 2

City

State

Zip Code

What country do you live in?

United States
Canada
Other

Date of Birth

Age

Email address

What is the best email(s) for us to communicate with you?

Phone Number

Weight in lbs.

For this type of surgery we need to know your height and weight.

Height in feet and inches

Medical History

Current Health Conditions

Do you have any health problems other than the pilonidal issue?

What previous operations have you had for your pilonidal problem (or indicate "none))

It is important that we know the name of any previous operations you've had, particularly if any involved a flap, such as a Limberg, Gluteal, or Rhomboid flap, a V-Y Plasty or Z Plasty, or a previous cleft lift.

Current medical history as it pertains to the pilonidal problem

What are your current symptoms? How has the pilonidal disease been bothering you?

What Medications are you Currently Taking?

Medication Allergies

Please list all medication allergies or any medications to which you have had side effects. If you are unable to swallow pills, let us know.

In the past, have you had GI Problems when taking antibiotics?

Symptoms like diarrhea, cramping, nausea, vomiting, etc.

Some specific medical questions:

Please answer each of these important questions. If they don't apply to you just answer "none" or "N/A".

Bleeding problems

Have ever had any bleeding problems with surgery, or any known coagulation disorder?

Previous Bacterial Cultures

Have you ever been diagnosed with MRSA (Methicillin Resistant Staph Aureus), or any other antibiotic resistant bacteria?

Skin Problems

Do you have any dermatologic problems, such as hidradenitis suppuritiva (HS), psoriasis, eczema, acne, etc.? If so, please tell us about them.

This is where you attach photos to this form.

The Photos need to be current, and show the up-to-date appearance of the wound. WE MUST HAVE THE EXACT PHOTOS SHOWN IN THE LINK, WHICH MEANS THERE SHOULD BE AT LEAST 2 IMAGES. (follow this link for examples on the photos needed - https://pilonidal.com/photos/) If you decide to send photos from any previous operations, please label them with the date of the photo and a history.

Important: The maximum size of this email form can only be 20 MB. If the photo sizes add up to more than this, the form will not come through. It would be best to make sure the photos are about 1-2 MB each, or that you submit the form more than once with a smaller number of attached images (if you have a lot of photos to share). The above link has some tips on how to make photos smaller.

Drag and drop you jpg photos here.

Drag & Drop Files, Choose Files to Upload You can upload up to 6 files.

Total size of file uploads can not exceed 20MB.

Medical History

Some specific medical questions:

This is where you attach photos to this form.

DON'T FORGET TO HIT THE SUBMIT BUTTON WHEN YOU ARE FINISHED.