| VASQIP 30 DAY FOLLOW-UP LETTER |
One month ago, you had an operation at the VA Medical Center. We are
If you answered NO, you do not need to answer any more questions. Please
return this sheet in the self-addressed stamped envelope.
If you have answered YES, please answer the following questions.
1) Have you been seen in an outpatient clinic or doctor's office ?
___ Yes ___ No
Why did you go to the clinic or doctor's office ? ________________
interested in how you feel. Have you had any health problems since your
Where ? (name and location) _____________________ Date ? ________
Who was your doctor ? ____________________________________________
2) Were you admitted to a hospital ? ___ Yes ___ No
Why did you go to the hospital ? _________________________________
Where ? (name and location) _____________________ Date ? ________
operation ? We would like to hear from you. Please take a few minutes
Who was your doctor ? ____________________________________________
Please return this letter whether or not you have had any medical
problems. Your health and opinion are important to us. Thank You.
Sincerely,
to answer these questions and return this letter in the self-addressed
Surgical Clinical Nurse Reviewer
stamped envelope.
Have you been to a hospital or seen a doctor for any reason since your
operation ? ___ Yes ___ No
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