Blank surgical outcomes form
 

SURGERY DATE:

AGE AT SURGERY DATE:

SURGEON:

SURGERY LOCATION/CLINIC:

DEVICE(s), LEVEL(s):

COST =
AMOUNT BILLED:
INSURANCE ALLOWED:
OUT OF POCKET:
TRAVEL:
EXPLANATIONS?


ONSET OF LUMBAR PROBLEMS, DATE OF INJURY, CAUSE, ETC...:

PRIOR SPINE SURGERIES AND PROCEDURES (IDET, ESI, etc...):

PRE-OP MEDICATIONS:

PRE-OP DIAGNOSTICS (discogram, nerve root blocks, etc...):

PRE-OP NEUROPATHIES (what, where, & degree of pain, numbness, tingling, sexual/bladder/bowel symptoms, etc.):

PRE-OP CONDITION (Please include %leg pain/% back pain, pain levels, type of pain, ability to work and function, disability status, etc.... be direct, but be as verbose as you need to):

TIME POST-OP AT ORIGINAL POST HERE:

DESCRIBE YOUR SURGICAL EXPERIENCE:

RATE FUNCTIONALITY / SATISFACTION AT INTERVALS BELOW:

FUNCTIONALITY:
1. Very poor: much worse... disabled after surgery.
2. Poor: worse after surgery.
3. Neutral: No improvement, or improvements offset by new problems.
4. Fair, some improvement, limitations are still serious.
5. Good, substantial improvement, some limitations.
6. Excellent: no limitations.

SATISFACTION:
1. Very sorry I had the surgery.
2. Somewhat sorry I had the surgery.
3. Too soon to tell, or I'm ambivalent about the surgery.
4. I'm somewhat glad I did my surgery.
5. I'm very glad I did my surgery.

Don't forget the detail update section below!

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [6 WEEKS POST-OP]

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [3 MONTHS POST-OP]

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [6 MONTHS POST-OP]

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [1 YEAR POST-OP]

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [2 YEARS POST-OP]

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [3 YEARS POST-OP]

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [4 YEARS POST-OP]

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [5 YEARS POST-OP]

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [6 YEARS POST-OP]

DATE UPDATED: _________ FUNCTIONALITY: ___ SATISFACTION: ___ [7 YEARS POST-OP]

6 WEEKS POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ECT... (discuss surgery induced symptoms [leg pain?]):

3 MONTHS POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ETC... (discuss surgery induced symptoms [leg pain?]):

6 MONTHS POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ETC... (discuss surgery induced symptoms [leg pain?]):

1 YEAR POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ETC... (discuss surgery induced symptoms [leg pain?]):

2 YEARS POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ETC... (discuss surgery induced symptoms [leg pain?]):

3 YEARS POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ETC... (discuss surgery induced symptoms [leg pain?]):

4 YEARS POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ETC... (discuss surgery induced symptoms [leg pain?]):

5 YEARS POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ETC... (discuss surgery induced symptoms [leg pain?]):

6 YEARS POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ETC... (discuss surgery induced symptoms [leg pain?]):

7 YEARS POST-OP - DESCRIBE LIFESTYLE / PAIN / MEDICATIONS / NEUROPATHIES / ETC... (discuss surgery induced symptoms [leg pain?]):