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Post Discectomy Form #2  [3 Weeks after Procedure]

Dr. Ditsworth's Patient Only.
If you had surgery with another Dr, please use different form.

Please Fill out all fields.

It will help us provide better care
if you answer the following questions 3 weeks after your procedure.
Name

Age

E-mail

Occupation

Today's Date(mm/dd/yy)

Date of procedure(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 arranged any type of traction at home. Please describe the device, how much you have used it and your response:

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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Symptoms
1.Sciatica;leg pain

2.Back Pain
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