Ens Treatment Testimony Form
ENS TREATMENT TESTIMONY FORM
FOR TREATMENT N
(ENS-TTFn)
0 INSTRUCTIONS
Please see the document INSTRUCTIONS.
III ENS TREATMENT No: (SELECT A NUMBER)
DATE (of filling in this form): Click here to enter a date (dd.mm.yyyy).
PATIENT INFORMATION
First name:Click here to enter text.
Surname: Click here to enter text.
3.1. GENERAL INFORMATION ABOUT TREATMENT
-> Date (of treatment): Click here to enter a date (dd.mm.yyyy).
-> Country (of treatment): Click here to enter text.
-> Clinic/Hospital: Click here to enter text.
-> Doctor: Click here to enter text.
3.2. TREATMENT DESCRIPTION
-> What kind of procedure(-es) was done (e.g. surgery, implant(s), injection(s), FESS, outfracture/infracture, etc): Click here to list.
-> Number of applications (if applicable, e.g. for injections): Select a number.
-> Material(-s) used (if applicable, e.g. ACell+PRP, REF-n, Alloderm, ear cartilage, etc):Click here to describe.
-> Where (location of) the procedure was performed (e.g. inferior/middle turbinate(s), septum, nasal floor, etc): Click here to describe.
-> Overall description of the procedure (in your own words): Click here to describe.
3.3.SUBJECTIVE ASSESSMENT OF RESULT
3.3.1. DETAILED
COMMENT:This section contains a detailed overview of treatment results over time (1 week, 1 month, 3 month, 6 months after treatment). If it is problematic to provide such a detailed assessment of the treatment, you can skip this (3.3.1)section and proceed tosection 3.3.2 (overall assessment of treatment results).It is essential that section 3.3.2be filled in(!)
* 1 week after treatment:
-> Level of improvement after treatment (0 – no improvement, 1 – very mild, 2 – mild, 3 – average, 4 – significant, 5 – very significant): Select a value.
-> Severity level of ENS symptoms after treatment (0 – no symptoms, 1 – very mild, 2 – mild, 3 – moderate, 4 – severe, 5 – extremely severe): Select a value.
-> Which symptoms improved: Click here to describe.
-> Which symptoms did not improve: Click here to describe.
+ Please attach SNOT-55 (optional, recommended)
* 1 month after treatment:
-> Level of improvement after treatment (0 – no improvement, 1 – very mild, 2 – mild, 3 – average, 4 – significant, 5 – very significant): Select a value.
-> Severitylevel of ENS symptoms after treatment (0 – no symptoms, 1 – very mild, 2 – mild, 3 – moderate, 4 – severe, 5 – extremely severe): Select a value.
-> Which symptoms improved: Click here to describe.
-> Which symptoms did not improve: Click here to describe.
+ Please attach SNOT-55 (optional, recommended)
* 3 months after treatment:
-> Level of improvement after treatment (0 – no improvement, 1 – very mild, 2 – mild, 3 – average, 4 – significant, 5 – very significant): Select a value.
-> Severitylevel of ENS symptoms after treatment (0 – no symptoms, 1 – very mild, 2 – mild, 3 – moderate, 4 – severe, 5 – extremely severe): Select a value.
-> Which symptoms improved: Click here to describe.
-> Which symptoms did not improve: Click here to describe.
+ Please attach SNOT-55 (optional, recommended)
* 6 monthsafter treatment:
-> Level of improvement after treatment (0 – no improvement, 1 – very mild, 2 – mild, 3 – average, 4 – significant, 5 – very significant): Select a value.
-> Severity level of ENS symptoms after treatment (0 – no symptoms, 1 – very mild, 2 – mild, 3 – moderate, 4 – severe, 5 – extremely severe): Select a value.
-> Which symptoms improved: Click here to describe.
-> Which symptoms did not improve: Click here to describe.
+ Please attach SNOT-55 (optional, recommended)
3.3.2. OVERALL
-> Estimation of the overall level of improvement aftertreatment (0 – no improvement, 1 – very mild, 2 – mild, 3 – average, 4 – significant, 5 – very significant): Select a value.
-> Theoverallseverity level of ENS symptoms after treatment (0 – no symptoms, 1 – very mild, 2 – mild, 3 – moderate, 4 – severe, 5 – extremely severe): Select a value.
-> Which symptoms improved: Click here to describe.
-> Which symptoms did not improve: Click here to describe.
+ Please attach SNOT-55 (optional, recommended)
3.4. OBJECTIVE ASSESSMENT OF RESULT
-> If you have any objective test(s) to assess results of thistreatment (e.g. CT scan, CFD study, endoscopy video/photo, biopsy, etc), please describe: Click here to enter text.
+ Please attach the tests(optional, recommended)
3.5. ASSESSMENT OF SERVICE
-> Attitude of personnel, doctor, quality of service (1 – very bad, 2 – bad, 3 – average, 4 – good, 5 – perfect): Select a value.
-> Comments (optional): Click here to enter text.
3.6. RECOVERY AFTER TREATMENT
-> Estimation of the level of “difficulty/severity” of the recovery period (1 – very easy, 2 – easy, 3 – moderate, 4 – difficult/severe, 5 – very difficult/severe): Select a value.
-> Length of the recovery period: Select a value.
-> Describe the recovery period(optional): Click here to describe.
3.7. ADDITIONAL INFORMATION
-> Additional comments (any information you would like to add regarding this treatment): Click here to enter text.
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