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Print this form and fill in the information if your doctor recommends that you have a surgical procedure.
What is the name of the surgical procedure?
Why do I need surgery?
How soon should surgery take place?
What might happen if I delay or avoid the surgery?
What results should I expect from the surgery?
Are there any nonsurgical options? Yes ___ No___ If yes, describe:
Are there any less invasive surgery options?
What is the next step if this surgery doesn't work?
How much does the surgery cost? How can I find out?
Can it be done on an outpatient basis, and is that less expensive?
What kind of preparation is needed for surgery?
Where will surgery be done?
How is the surgery done (laparoscopy or open surgery)?
What kind of anesthesia will be used (general, local, or regional)?
How long will the procedure take?
How successful is this procedure?
What are the risks associated with this surgery?
How much experience does the surgeon have with this procedure?
Has the procedure been done often in this hospital or surgery center? Yes ___ No___
What complications might develop (both immediate and long-term)?
If a biopsy is being done, when can I expect to hear the results, and will my doctor call me?
How long will I have to stay after surgery?
How will I feel after surgery?
How much pain is there after this type of surgery? How is it treated?
How long will it take to recover from surgery?
What kind of care will I need at home? Are there any activity limitations?
How soon can I eat a regular meal?
How soon can I resume regular activities?
What symptoms should I watch for and report?
ByHealthwise StaffPrimary Medical Reviewer Anne C. Poinier, MD - Internal Medicine Adam Husney, MD - Family Medicine Kenneth Bark, MD - General Surgery, Colon and Rectal Surgery
Current as ofMarch 29, 2018
Current as of:
March 29, 2018
Anne C. Poinier, MD - Internal Medicine & Adam Husney, MD - Family Medicine & Kenneth Bark, MD - General Surgery, Colon and Rectal Surgery