{"id":433,"date":"2021-11-16T00:42:45","date_gmt":"2021-11-16T00:42:45","guid":{"rendered":"https:\/\/backinstituteneurosurgery.com\/web\/?page_id=433"},"modified":"2023-07-22T23:33:01","modified_gmt":"2023-07-22T23:33:01","slug":"more-than-1-week-post-surgery-form","status":"publish","type":"page","link":"https:\/\/backinstituteneurosurgery.com\/main\/more-than-1-week-post-surgery-form\/","title":{"rendered":"More than 1 week post surgery form"},"content":{"rendered":"<div class=\"everest-forms\"><div class=\"evf-container default\" id=\"evf-928\"><form id=\"evf-form-928\" class=\"everest-form\" data-formid=\"928\" data-ajax_submission=\"0\" data-keyboard_friendly_form=\"0\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/main\/wp-json\/wp\/v2\/pages\/433\"><div class=\"evf-field-container\"><input type=\"hidden\" id=\"_wpnonce928\" name=\"_wpnonce928\" value=\"66ff58739b\" \/><input type=\"hidden\" name=\"_wp_http_referer\" value=\"\/main\/wp-json\/wp\/v2\/pages\/433\" \/><div class=\"evf-frontend-row\" data-row=\"row_1\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_1\"><div id=\"evf-928-field_a5bZwD9Fa2-1-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"a5bZwD9Fa2-1\"><label class=\"evf-field-label\" for=\"evf-928-field_a5bZwD9Fa2-1\"><span class=\"evf-label\">Name<\/span> <\/label><input type=\"text\" id=\"evf-928-field_a5bZwD9Fa2-1\" class=\"input-text\" name=\"everest_forms[form_fields][a5bZwD9Fa2-1]\" ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_2\"><div id=\"evf-928-field_oi4XHysAcZ-2-container\" class=\"evf-field evf-field-email form-row validate-email\" data-field-id=\"oi4XHysAcZ-2\"><label class=\"evf-field-label\" for=\"evf-928-field_oi4XHysAcZ-2\"><span class=\"evf-label\">Email<\/span> <\/label><input type=\"email\" id=\"evf-928-field_oi4XHysAcZ-2\" class=\"input-text\" name=\"everest_forms[form_fields][oi4XHysAcZ-2]\"  ><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_2\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_1\"><div id=\"evf-928-field_lCyyKyzFGh-4-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"lCyyKyzFGh-4\"><label class=\"evf-field-label\" for=\"evf-928-field_lCyyKyzFGh-4\"><span class=\"evf-label\">Age<\/span> <\/label><input type=\"text\" id=\"evf-928-field_lCyyKyzFGh-4\" class=\"input-text\" name=\"everest_forms[form_fields][lCyyKyzFGh-4]\" ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_2\"><div id=\"evf-928-field_otY0CuaZ4a-5-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"otY0CuaZ4a-5\"><label class=\"evf-field-label\" for=\"evf-928-field_otY0CuaZ4a-5\"><span class=\"evf-label\">Occupation<\/span> <\/label><input type=\"text\" id=\"evf-928-field_otY0CuaZ4a-5\" class=\"input-text\" name=\"everest_forms[form_fields][otY0CuaZ4a-5]\" ><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_3\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_1\"><div id=\"evf-928-field_4aIOsf5AxY-6-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"4aIOsf5AxY-6\"><label class=\"evf-field-label\" for=\"evf-928-field_4aIOsf5AxY-6\"><span class=\"evf-label\">City<\/span> <\/label><input type=\"text\" id=\"evf-928-field_4aIOsf5AxY-6\" class=\"input-text\" name=\"everest_forms[form_fields][4aIOsf5AxY-6]\" ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_2\"><div id=\"evf-928-field_xwPAvM60fX-7-container\" class=\"evf-field evf-field-text form-row\" data-field-id=\"xwPAvM60fX-7\"><label class=\"evf-field-label\" for=\"evf-928-field_xwPAvM60fX-7\"><span class=\"evf-label\">State<\/span> <\/label><input type=\"text\" id=\"evf-928-field_xwPAvM60fX-7\" class=\"input-text\" name=\"everest_forms[form_fields][xwPAvM60fX-7]\" ><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_4\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_1\"><div id=\"evf-928-field_YBpkQWsteI-8-container\" class=\"evf-field evf-field-date-time form-row\" data-field-id=\"YBpkQWsteI-8\"><label class=\"evf-field-label\" for=\"evf-928-field_YBpkQWsteI-8\"><span class=\"evf-label\">Today's Date<\/span> <\/label><input type=\"text\" id=\"evf-928-field_YBpkQWsteI-8\" class=\"flatpickr-field input-text\" name=\"everest_forms[form_fields][YBpkQWsteI-8]\" data-time-interval=\"15\" data-date-time=\"date\" data-mode=\"single\" data-locale=\"en\" data-date-format=\"Y-m-d\"  ><\/div><\/div><div class=\"evf-frontend-grid evf-grid-2\" data-grid=\"grid_2\"><div id=\"evf-928-field_1ssdIHoot6-9-container\" class=\"evf-field evf-field-date-time form-row\" data-field-id=\"1ssdIHoot6-9\"><label class=\"evf-field-label\" for=\"evf-928-field_1ssdIHoot6-9\"><span class=\"evf-label\">Date of Surgery<\/span> <\/label><input type=\"text\" id=\"evf-928-field_1ssdIHoot6-9\" class=\"flatpickr-field input-text\" name=\"everest_forms[form_fields][1ssdIHoot6-9]\" data-time-interval=\"15\" data-date-time=\"date\" data-mode=\"single\" data-locale=\"en\" data-date-format=\"Y-m-d\"  ><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_5\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-928-field_RjLPCsdy0u-10-container\" class=\"evf-field evf-field-checkbox form-row\" data-field-id=\"RjLPCsdy0u-10\"><label class=\"evf-field-label\" for=\"evf-928-field_RjLPCsdy0u-10\"><span class=\"evf-label\">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?<\/span> <\/label><ul id=\"evf-928-field_RjLPCsdy0u-10\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_RjLPCsdy0u-10_1\" class=\"input-text\" name=\"everest_forms[form_fields][RjLPCsdy0u-10][]\" value=\"Yes\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_RjLPCsdy0u-10_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_RjLPCsdy0u-10_2\" class=\"input-text\" name=\"everest_forms[form_fields][RjLPCsdy0u-10][]\" value=\"No\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_RjLPCsdy0u-10_2\">No<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_6\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-928-field_IquAXQPP1b-12-container\" class=\"evf-field evf-field-checkbox form-row\" data-field-id=\"IquAXQPP1b-12\"><label class=\"evf-field-label\" for=\"evf-928-field_IquAXQPP1b-12\"><span class=\"evf-label\">Are you handicapped by severe pain?<\/span> <\/label><ul id=\"evf-928-field_IquAXQPP1b-12\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_IquAXQPP1b-12_1\" class=\"input-text\" name=\"everest_forms[form_fields][IquAXQPP1b-12][]\" value=\"Yes\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_IquAXQPP1b-12_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_IquAXQPP1b-12_2\" class=\"input-text\" name=\"everest_forms[form_fields][IquAXQPP1b-12][]\" value=\"No\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_IquAXQPP1b-12_2\">No<\/label><\/li><\/ul><\/div><\/div><\/div><div class=\"evf-frontend-row\" data-row=\"row_7\" conditional_rules=\"[]\"><div class=\"evf-frontend-grid evf-grid-1\" data-grid=\"grid_1\"><div id=\"evf-928-field_epQnKTyS6M-13-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"epQnKTyS6M-13\"><label class=\"evf-field-label\" for=\"evf-928-field_epQnKTyS6M-13\"><span class=\"evf-label\">How are your symptoms different in comparison to prior to your procedure?<\/span> <\/label><textarea id=\"evf-928-field_epQnKTyS6M-13\" class=\"input-text\" name=\"everest_forms[form_fields][epQnKTyS6M-13]\"  ><\/textarea><\/div><div id=\"evf-928-field_DH1KmzJtoj-14-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"DH1KmzJtoj-14\"><label class=\"evf-field-label\" for=\"evf-928-field_DH1KmzJtoj-14\"><span class=\"evf-label\">What medication are you taking and what is the total daily dosage?<\/span> <\/label><textarea id=\"evf-928-field_DH1KmzJtoj-14\" class=\"input-text\" name=\"everest_forms[form_fields][DH1KmzJtoj-14]\"  ><\/textarea><\/div><div id=\"evf-928-field_H7lHo2nI18-15-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"H7lHo2nI18-15\"><label class=\"evf-field-label\" for=\"evf-928-field_H7lHo2nI18-15\"><span class=\"evf-label\">Are you having or have you had any physical therapy(at home or at a therapy center?)Please describe:<\/span> <\/label><textarea id=\"evf-928-field_H7lHo2nI18-15\" class=\"input-text\" name=\"everest_forms[form_fields][H7lHo2nI18-15]\"  ><\/textarea><\/div><div id=\"evf-928-field_mhIoM0tZPY-16-container\" class=\"evf-field evf-field-checkbox form-row\" data-field-id=\"mhIoM0tZPY-16\"><label class=\"evf-field-label\" for=\"evf-928-field_mhIoM0tZPY-16\"><span class=\"evf-label\">Have you done therapy per our protocol, or extended protocol?<\/span> <\/label><ul id=\"evf-928-field_mhIoM0tZPY-16\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_mhIoM0tZPY-16_1\" class=\"input-text\" name=\"everest_forms[form_fields][mhIoM0tZPY-16][]\" value=\"Yes\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_mhIoM0tZPY-16_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_mhIoM0tZPY-16_2\" class=\"input-text\" name=\"everest_forms[form_fields][mhIoM0tZPY-16][]\" value=\"No\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_mhIoM0tZPY-16_2\">No<\/label><\/li><\/ul><\/div><div id=\"evf-928-field_rhDyLdBJ84-17-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"rhDyLdBJ84-17\"><label class=\"evf-field-label\" for=\"evf-928-field_rhDyLdBJ84-17\"><span class=\"evf-label\">If NO, please describe why not:<\/span> <\/label><textarea id=\"evf-928-field_rhDyLdBJ84-17\" class=\"input-text\" name=\"everest_forms[form_fields][rhDyLdBJ84-17]\"  ><\/textarea><\/div><div id=\"evf-928-field_f1UIxm1CuU-18-container\" class=\"evf-field evf-field-checkbox form-row\" data-field-id=\"f1UIxm1CuU-18\"><label class=\"evf-field-label\" for=\"evf-928-field_f1UIxm1CuU-18\"><span class=\"evf-label\">Is there any stress to your spine during therapy?<\/span> <\/label><ul id=\"evf-928-field_f1UIxm1CuU-18\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_f1UIxm1CuU-18_1\" class=\"input-text\" name=\"everest_forms[form_fields][f1UIxm1CuU-18][]\" value=\"Yes\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_f1UIxm1CuU-18_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_f1UIxm1CuU-18_2\" class=\"input-text\" name=\"everest_forms[form_fields][f1UIxm1CuU-18][]\" value=\"No\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_f1UIxm1CuU-18_2\">No<\/label><\/li><\/ul><\/div><div id=\"evf-928-field_XLC6KfWFQk-19-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"XLC6KfWFQk-19\"><label class=\"evf-field-label\" for=\"evf-928-field_XLC6KfWFQk-19\"><span class=\"evf-label\">If YES, please describe:<\/span> <\/label><textarea id=\"evf-928-field_XLC6KfWFQk-19\" class=\"input-text\" name=\"everest_forms[form_fields][XLC6KfWFQk-19]\"  ><\/textarea><\/div><div id=\"evf-928-field_4u99ZIY4Jy-20-container\" class=\"evf-field evf-field-checkbox form-row\" data-field-id=\"4u99ZIY4Jy-20\"><label class=\"evf-field-label\" for=\"evf-928-field_4u99ZIY4Jy-20\"><span class=\"evf-label\">Has there been any problem with physical therapy?<\/span> <\/label><ul id=\"evf-928-field_4u99ZIY4Jy-20\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_4u99ZIY4Jy-20_1\" class=\"input-text\" name=\"everest_forms[form_fields][4u99ZIY4Jy-20][]\" value=\"Yes\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_4u99ZIY4Jy-20_1\">Yes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"evf-928-field_4u99ZIY4Jy-20_2\" class=\"input-text\" name=\"everest_forms[form_fields][4u99ZIY4Jy-20][]\" value=\"No\"  ><label class=\"everest-forms-field-label-inline\" for=\"evf-928-field_4u99ZIY4Jy-20_2\">No<\/label><\/li><\/ul><\/div><div id=\"evf-928-field_cVx3TZqPIl-21-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"cVx3TZqPIl-21\"><label class=\"evf-field-label\" for=\"evf-928-field_cVx3TZqPIl-21\"><span class=\"evf-label\">If YES, please describe:<\/span> <\/label><textarea id=\"evf-928-field_cVx3TZqPIl-21\" class=\"input-text\" name=\"everest_forms[form_fields][cVx3TZqPIl-21]\"  ><\/textarea><\/div><div id=\"evf-928-field_8zCczXlJxv-22-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"8zCczXlJxv-22\"><label class=\"evf-field-label\" for=\"evf-928-field_8zCczXlJxv-22\"><span class=\"evf-label\">Please provide the name and phone number of your PT facility:<\/span> <\/label><textarea id=\"evf-928-field_8zCczXlJxv-22\" class=\"input-text\" name=\"everest_forms[form_fields][8zCczXlJxv-22]\"  ><\/textarea><\/div><div id=\"evf-928-field_vLECopFJ4N-23-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"vLECopFJ4N-23\"><label class=\"evf-field-label\" for=\"evf-928-field_vLECopFJ4N-23\"><span class=\"evf-label\">When did you return to work?<\/span> <\/label><textarea id=\"evf-928-field_vLECopFJ4N-23\" class=\"input-text\" name=\"everest_forms[form_fields][vLECopFJ4N-23]\"  ><\/textarea><\/div><div id=\"evf-928-field_77Ps4B5920-24-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"77Ps4B5920-24\"><label class=\"evf-field-label\" for=\"evf-928-field_77Ps4B5920-24\"><span class=\"evf-label\">Are you working at the same job as prior to the start of your back problem? If a different job, please describe:<\/span> <\/label><textarea id=\"evf-928-field_77Ps4B5920-24\" class=\"input-text\" name=\"everest_forms[form_fields][77Ps4B5920-24]\"  ><\/textarea><\/div><div id=\"evf-928-field_MmXGemSaUB-25-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"MmXGemSaUB-25\"><label class=\"evf-field-label\" for=\"evf-928-field_MmXGemSaUB-25\"><span class=\"evf-label\">Working full time?<\/span> <\/label><textarea id=\"evf-928-field_MmXGemSaUB-25\" class=\"input-text\" name=\"everest_forms[form_fields][MmXGemSaUB-25]\"  ><\/textarea><\/div><div id=\"evf-928-field_kyAiUcMQuG-26-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"kyAiUcMQuG-26\"><label class=\"evf-field-label\" for=\"evf-928-field_kyAiUcMQuG-26\"><span class=\"evf-label\">No limitation or if there is a limitation at work, please describe:<\/span> <\/label><textarea id=\"evf-928-field_kyAiUcMQuG-26\" class=\"input-text\" name=\"everest_forms[form_fields][kyAiUcMQuG-26]\"  ><\/textarea><\/div><div id=\"evf-928-field_LUyh3bXINl-28-container\" class=\"evf-field evf-field-textarea form-row\" data-field-id=\"LUyh3bXINl-28\"><label class=\"evf-field-label\" for=\"evf-928-field_LUyh3bXINl-28\"><span class=\"evf-label\">What activities are you doing?<\/span> <\/label><textarea id=\"evf-928-field_LUyh3bXINl-28\" class=\"input-text\" name=\"everest_forms[form_fields][LUyh3bXINl-28]\"  ><\/textarea><\/div><\/div><\/div><\/div><div class=\"evf-honeypot-container evf-field-hp\"><label for=\"evf-928-field-hp\" class=\"evf-field-label\">Phone<\/label><input type=\"text\" name=\"everest_forms[hp]\" id=\"evf-928-field-hp\" class=\"input-text\"><\/div><div class=\"evf-submit-container \" ><input type=\"hidden\" name=\"everest_forms[id]\" value=\"928\"><input type=\"hidden\" name=\"everest_forms[author]\" value=\"1\"><button type='submit' name='everest_forms[submit]' class='everest-forms-submit-button button evf-submit ' id='evf-submit-928' value='evf-submit' data-process-text=\"Processing\u2026\" conditional_rules='&quot;&quot;' conditional_id='evf-submit-928'  id=\"evf-submit-928\" aria-live=\"assertive\">Submit<\/button><\/div><\/form><\/div><!-- .evf-container --><\/div>\n","protected":false},"excerpt":{"rendered":"","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"full-width.php","meta":{"footnotes":""},"class_list":["post-433","page","type-page","status-publish","hentry"],"_links":{"self":[{"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages\/433","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/comments?post=433"}],"version-history":[{"count":1,"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages\/433\/revisions"}],"predecessor-version":[{"id":932,"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/pages\/433\/revisions\/932"}],"wp:attachment":[{"href":"https:\/\/backinstituteneurosurgery.com\/main\/wp-json\/wp\/v2\/media?parent=433"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}