Patient Evaluation Form
(Surgical)

1. Patient Information

2. Pain Synopsis

Have pain symptoms changed within the past 6-12 months?

YesNo

Back / Leg Pain
Choose one

Neck / Arm Pain
Choose one

Pain Levels (0 = no pain - 10 = constant extreme pain) (please rate your AVERAGE PAIN)

* When you have the least amount of pain, what number would that be between 0 and 10.

* When you have the most amount of pain, what number would that be between 0 and 10.

* i.e. 20 days of the month you have a Minimum (3) pain, but 10 days of the month you have a Maximum (9) pain. So therefore the Average pain may be closer to the Minimum side than to the Maximum side of pain giving you an Average # of possibly (5).
Minimum pain
Maximum pain
Average pain at its Worst
Average pain at its Best

Tolerances / Endurance (maximum time / distance)

3. Personal Health Information

Other Co-Existing Health issues (such as high blood pressure, cholesterol, depression, diabetes, heart disease, pace maker, asthma, kidney or liver disease, cancer, other?)

4. Case History - Work involvement & leisure activities

The physical strain in job and leisure time plays a major role for orthopedic diagnosis and therapy.
This questionnaire will therefore help us to give you a proper evaluation.

Have you had to stop working or change occupations because of your condition?

YesNo

Your present occupation, is it :

Physical workNon-physical workNot workingOther

Under which of these conditions are you working?

Full timePart timeNot workingOther

Is your occupation physically straining for you?

YesNo

Is your occupation associated with monotonous body postures?

YesNoNot working

Does your pain make it difficult to work?

YesNoNot working

Do your symptoms allow you to play sports / exercise?

YesNo

If NO, did you do any sports / exercise before?

YesNo

Will you have someone to support you at home after surgery?

YesNo

Declaration

I hereby declare that all information provided in this form is correct and true, to the best of my knowledge. I understand that not disclosing known underlying disease or health conditions may affect my suitability and/or acceptance for medical treatment.

*You will automatically receive an Email copy of this form for safe keeping.

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