Work-related issues Off work/missed work/ unable to work because of hernia – Domestic activities Carer responsibilities Please provide details of the impact: YES NO Is the patient currently asymptomatic but works in a heavy manual occupation and has an increased risk of strangulation and further complications? Please provide details: If appropriate, please confirm the patient has completed the Patient Decision Aid YES NO for Inguinal hernia and it is included as clinical evidence. Patient’s Body Mass Index: Is the patient a non-smoker? YES NO DATE: SIGNATURE OF CLINICIAN ……………………………………………………………. ………………………………………………….. Please email the completed form to for consideration.
Work-related issues – Off work/missed work/ unable to work because of hernia Domestic activities Carer responsibilities Please provide details of the impact: Is the patient currently asymptomatic but works in a heavy manual occupation and has an increased risk of strangulation and further complications? Please provide details: YES NO If appropriate, please confirm the patient has completed the Patient Decision Aid for Inguinal hernia and it is included as clinical evidence. YES NO Patient’s Body Mass Index: Is the patient a non-smoker? YES NO SIGNATURE OF CLINICIAN ……………………………………………………………. DATE: ………………………………………………….. Please email the completed form to for consideration.
Hernia-Form-January-2018-BD.docx