Capital Surgical Associates

Capital Surgical Associates

Daniel Gay, DO, FACOS  ·  capsurgical.com

HerQLes
Patient-Reported Outcomes  ·  AHSQC

HerQLes Patient Outcome Survey

Your responses help Dr. Gay track your recovery and deliver the best possible hernia care.

0 of 15 questions answered

What is the HerQLes Survey?

The Hernia-Related Quality-of-Life Survey (HerQLes) is a validated patient-reported outcome measure (PROM) developed by the Americas Hernia Society Quality Collaborative (AHSQC). It measures how your abdominal wall hernia affects daily activities, pain, and overall quality of life — before and after surgery.

Completing this survey at each visit gives Dr. Gay objective data to personalize your care and track your recovery over time.

Patient Information
Required to match your record
Please enter your first name.
Please enter your last name.
Please select your visit type.
Your Experience
In your own words (optional)
Hernia Status
Based on your current experience
Pain Assessment
In the past 7 days — select the number that best describes your pain.
How intense was your pain at its worst?
No painMildModerateSevereVery Severe
How intense was your average pain?
No painMildModerateSevereVery Severe
What is your level of pain right now?
No painMildModerateSevereVery Severe
Abdominal Wall Impact
1 = Strongly Disagree  ·  6 = Strongly Agree
Strongly
Disagree Moderately
Disagree Slightly
Disagree Slightly
Agree Moderately
Agree Strongly
Agree

Your responses are sent securely to Capital Surgical Associates.

Thank You!

Your HerQLes survey has been received. Dr. Gay's team will review your responses before your appointment.

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