Patient History Form

Patient First Name *

Patient Last Name *

Gender *

Number problems Age

Address *

Address Line 1

Address Line 2

City

State

Zip Code

What country do you live in? *

Date of Birth *

Age *

Email address *

Phone Number *

Weight in lbs.

For cleft lift surgery we need to know your weight

Height in feet and inches *

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

Current medical history as it pertains to the pilonidal problem *

What Medications are you Currently Taking? *

Medication Allergies *

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

Have you had bleeding problems with surgery? *

Have you had any previous bacterial cultures that we should be aware of? *

Have you ever been diagnosed with MRSA bacteria?

Do you have any skin or dermatologic problems? *

In particular have you been diagnosed with hidradenitis suppuritiva (HS), psoriasis, cystic acne, or any other skin problem?

Do you have diabetes? *

Have you ever been diagnosed with an autoimmune disease? *

Are you taking any immune suppressing medications? *

Drag and drop your jpg photos here. As described on https://www.pilonidal.com/photos

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

The link above explains exactly which photos we need.

Important: This form can only send about 20 MB total.

• Each photo should be about 1–2 MB
• Limit uploads to 3–5 photos per submission
• You may submit the form more than once if needed

iPhone users: If photos are too large, go to Settings → Camera → Formats → Most Compatible

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