More than 1 week post surgery form Name Email Age Occupation City State Today's Date Date of Surgery 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? YesNoAre you handicapped by severe pain? YesNoHow are your symptoms different in comparison to prior to your procedure? What medication are you taking and what is the total daily dosage? 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? YesNoIf NO, please describe why not: Is there any stress to your spine during therapy? YesNoIf YES, please describe: Has there been any problem with physical therapy? YesNoIf 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: EmailSubmit
