PATIENT'S NAME ______________________________________

ADDRESS ____________________________________________

ADDRESS ____________________________________________

PHONE NUMBER ______________________________________

SURGEON ____________________________________________

DATE OF SURGERY ____________________________________

You (or your child) had surgery performed in the recent past. For the benefit of all our patients and physicians, we are trying to determine how successful our recommended surgeries are in eliminating the patient's problems. We ask you to take a minute and answer the following 8 questions.

1. How many throat infections consisting of fever, swollen tonsils, and swallowing trouble have you or your child had in the last 12 months?
0	1 or 2	3 to 5	more than 5
2. How many times in the last year have you or your child seen the doctor or received antibiotics for throat infections?
0	1 or 2	3 to 5	more than 5
3. Do you or your child snore loudly now and/or stop breathing at night?
Yes	No
4. Do you or your child have chronic bad breath now?
Yes	No
5. Overall compared to before the surgery, are your (or your child's) symptoms:
Resolved	Better	About the Same	Worse
6. Did you (or your child) have bleeding after your surgery requiring a return visit to the operating room to control?
Yes	No
7. Did the surgery meet your goals and expectations?
Yes	No
8. Would you still have the surgery if you had the whole thing to do over again?
Yes	No

* Please print this form, complete it and bring or mail it to our office. Our mailing address can be obtained from our Office Information page.