Q1 Where is your hernia?   Abdominal wall Groin Right Left     Q2 Are you having pain in the area of your hernia?   Yes No If yes , please rate it from 1 -10 with 10 being unbearable:     Q3 Do you notice a bulge or swelling in the area of your hernia?       Q4 How long have you had your hernia?       Q5 If you have had previous hernia surgery, please state what procedure you had and the year it was done:       Q6 Was there a previous surgical incision in the area of your hernia?   Yes No If yes, what operation was this?     Q7 Please describe any physical activity that you perform at work:       Q8 Please describe sports that you frequently perform:       Q9 Who if anyone in your family has had a hernia?       Q10 Are you taking any pain medications at this time?   Yes No If yes, what medications?     Q11 If there was a specific incident that brought on your hernia, please describe it:       Q12 Please select any of the following conditions that you have been treated for:   Hypertension Diabetes Mellitus Coronary Artery Disease Heart Attack Heart Valvular Disease Heart Rhythm Problem Elevated cholesterol or triglyceride Stroke TIA Peripheral Vascular Disease Kidney Failure or insufficiency Chronic Obstructive Pulmonary Disease Asthma Emphysema Cancer Gastroesophageal Reflux Irritable Bowel Syndrome Peptic Ulcer Disease Kidney stones         Q13 Please list any previous surgery and their respective dates:       Q14 Please list current medications:       Q15 Please list any allergies to medications:       Q16 How many cigarettes do you smoke per day?         Thank You Contact Information First Name* : Last Name : E-Mail * : Age* : Phone Number* : Fax Number : E-MAIL ADDRESS needed here for return response* : Comments: :      (Fields marked with an asterisk * are required)