More than 1 Week Post surgery form

This area is only for the patients who had surgery with us.

Contact Information:
Name Email
Age Occupation
City State
Medical Information:
Today's Date(mm/dd/yy)
Date of surgery(mm/dd/yy)
Do you have occasional back or leg pain (neck or arm pain, if it was a neck problem) severe enough to interfere with normal work or leisure activities? Yes No
Are you handicapped by severe pain? Yes No
How are your symptoms different
in comparison to prior to your procedure?
What medication are you taking and how often?
Are you having or have you had any physical therapy(at home or at a therapy center?)Please describe:
Have you done therapy per our protocol, or extended protocol? Yes No
If NO, please describe why not:
Is there any stress to your spine during therapy? Yes No
If YES, please describe:
Has there been any problem with physical therapy? Yes No
If YES, please describe:
Please provide the name of your PT facility:
When did you return to work?
Are you working at the same job as prior to the start of your back problem? If a different job, please describe:
Working full time?
No limitation or if there is a limitation at work, please describe:

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