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Self-Assessment Tool

Find out if you may be at risk for adhesions. The self-assessment tool allows you to evaluate your health and review your symptoms.

Self-Assessment Tool

Use the CAPPS self-assessment tool to determine if you are at risk for adhesions.

Self-Assessment Tool

Florida Hospital Celebration Health has designed a self-assessment tool for visitors to complete a high level adhesions analysis to determine if one may be at risk. Complete the form fully for best results.

Health Assessment

Have you ever had abdominal surgery?:

No

Yes

Have you ever had pelvic surgery?:

No

Yes

Have you ever had endometriosis?:

No

Yes

Have you ever had interstitial cystitis?:

No

Yes

Review of Symptoms

Nausea or Vomiting:

No

Yes

Stomach Pain:

No

Yes

Recent weight change:

No

Yes

Poor appetite:

No

Yes

Diarrhea or loose stools:

No

Yes

Blood in bowel movement:

No

Yes

Frequent urination:

No

Yes

Frequent constipation:

No

Yes

Difficulty or pain while urinating:

No

Yes

Blood in urine:

No

Yes

Depression:

No

Yes

Pain / Comfort Assessment

Where is your pain problem (location)?:

How would you describe the onset of your pain?:

What is your level of pain (0=minor, 10=intense):

0

1

2

3

4

5

6

7

8

9

10

Primary Links

For Physicians
Our Program
Self-Assessment Tool
Patient Registration Form
About
Forums
Contact