Patient Survey - General Information

The Center for Spinal Disorders is committed to our reputation for providing the best spinal surgical care. However, commitment and reputation are not enough. The future availability of surgery like yours depends on our ability to meet an ever-increasing demand by the government and insurers for proven outcomes. By providing honest, accurate information about the results of your surgery through this outcomes survey, you will help your surgeons to develop new techniques and improve surgical results.

PLEASE READ EACH QUESTION CAREFULLY, so that your answers can be as accurate as possible.

No survey is perfect, and in some cases answers do not fit your situation exactly. Please just select the answer that fits you best.

We know that some of the questions in this survey appear redundant. Our survey includes proven questions used in the medical literature (SF-36, Oswestry, Neck Disability Index, and SRS-22). In order for our survey to be valid, we must ask the questions in exactly the way they are on the original surveys. This results in overlap that may appear redundant, and is also why some of the questions seem poorly worded or hard to fit to you.

You may take as long as you like to complete the survey, but if you exit, your answers will be lost and you will have to begin again.

Again, we appreciate your time and patience with these questions. Your time on this survey will help us to improve care to patients like you. Please press NEXT on each page to continue!

1. General Information

Name:
Email Address:
Phone Number:

2. Who is your surgeon

Dr. Edward Song
Dr. William Stevens

3. Who is completing this survey?

	The patient
	The patient's spouse
	The patient's parent or guardian
	The patient with help of someone to translate or enter information
	Center for Spinal Disorders staff member

4. Are you completing this survey before of after your surgery? Please select the closest answer below - the exact timing is not critical.

	I am completing this survey BEFORE my surgery (Pre-Op survey)
	I had surgery approximately 3 MONTHS ago (3-Month Post-Op)
	I had surgery approximately 6 MONTHS ago (6-Month Post-Op)
	I had surgery about 1 YEAR AGO (1-Year Post-Op)
	I had surgery about 2 YEARS AGO (2-Year Post-Op)
	I am completing this survey three or more years after my surgery (Please enter number of years since your surgery)

5. When was/is the date of your surgery?

	I have not yet had my surgery but it is schedule for

	My surgery was completed on

6. Do you have a spinal deformity?

	Yes
	No

7. Are you being treated by Center for Spinal Disorders for your neck?

	Yes
	No