|
Interval between surgery and examination
|
|
|
|
Which of the following problems related to your back condition troubles you the most:Find:Pt:^Patient:Ord:
|
|
|
|
Pain severity + Body site Pnl
|
|
Pain severity + Body site Pnl
|
|
Hlth cond interfere with normal work past W
|
|
|
|
If you had to spend the rest of your life with the symptoms you have right now how would you feel about it:Find:Pt:^Patient:Ord:
|
|
|
|
Quality of life in past W
|
|
|
|
#D cut down activities hlt cond 4W
|
|
|
|
#D didn't go to work due to health cond
|
|
|
|
Type of postoperative complication
|
|
|
|
Postop complication distress level
|
|
|
|
Subsequent operation for same condition
|
|
|
|
Pt satisfaction w healthcare
?
|
|
|
|
Treatment effectiveness
|
|
|
|
Date form completed
|
|
{mm/dd/yyyy}
|
|
Signature verifying assessment completion:Pn:Pt:^Patient:Nom:
|
|
|
|
Core Outcome Measures Index for the Back score:Score:Pt:^Patient:Qn:COMI
©
|
|
{score}
|
|
Pain severity Reported
|
|
|
|
Bdy site
E
|
|
|