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.


Join Our Youtube Channel

Watch videos showcasing the latest technologies and surgery techniques, and keep up to date with patient stories from around the globe.