Post-Procedure Rest Instructions Form
Please complete this form to confirm your rest instructions and report your current status after your procedure.
Full Name
*
First Name
Last Name
Procedure Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Did you follow the prescribed rest instructions?
*
Yes
No
Partially
Which rest instructions did you find challenging to follow?
Are you currently experiencing any of the following symptoms?
Fever
Increased pain
Swelling
Redness
Nausea
Other
Please rate your current level of discomfort or pain.
*
No discomfort
0
1
2
3
4
5
6
7
8
9
Severe discomfort
10
0 is No discomfort, 10 is Severe discomfort
Have you taken all prescribed medications as directed?
*
Yes
No
Not applicable
If you missed any medications, please specify which ones and why.
Would you like to request a follow-up call or appointment?
*
Yes, please contact me
No, I do not need follow-up
Additional comments or concerns
Submit
Should be Empty: