AX Post Market Survey Location and Physician Question Title * 1. Hospital Name Question Title * 2. Address Address Address 2 City/Town State/Province -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code Phone Number Question Title * 3. Physician Name Patient Demographics Question Title * 4. Patient Gender Male Female Question Title * 5. Patient Age Question Title * 6. Patient Weight Question Title * 7. Patient Height Question Title * 8. Indication Procedure Question Title * 9. Segments L2/L3 L3/L4 L4/S1 L4/L5 L5/S1 Other (please specify) Question Title * 10. Disc Removed 0% 50% 100% Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 11. Disc space description (Check all that apply) Collapsed Open Rigid Flexible Hyper Lordotic Other (please specify) Question Title * 12. Operation date and time Date / Time Date Time AM/PM - AM PM Question Title * 13. Total operative time (00:00) Implants used Question Title * 14. Instruments used (check any used) Fixed Angle Bone Awl Straight Bone Awl Fixed Angle Driver Straight Driver Variable Angle Driver Straight Inserter Offset Inserter Disc Spreader Trial Inserter Cover Plate Inserter Slide Hammer Mallet Tamp Palm Handle Torque Driver Other (please specify) Question Title * 15. Implant height 10mm 12mm 14mm 16mm 18mm 20mm Question Title * 16. Screw length 20mm 25mmm 30mm Question Title * 17. Degree 8 14 20 30 Question Title * 18. Width 30mm 36mm 40mm Question Title * 19. Cap size Small Large Question Title * 20. Use (per level) Single Pairs Question Title * 21. Rate each instrument Below Average Average Above Average Exceptional Trials- Ease of Insertion Trials- Ease of Insertion Below Average Trials- Ease of Insertion Average Trials- Ease of Insertion Above Average Trials- Ease of Insertion Exceptional Trials- Removal from Disc Space Trials- Removal from Disc Space Below Average Trials- Removal from Disc Space Average Trials- Removal from Disc Space Above Average Trials- Removal from Disc Space Exceptional Trials- Overall Design Trials- Overall Design Below Average Trials- Overall Design Average Trials- Overall Design Above Average Trials- Overall Design Exceptional Handles- Weight Handles- Weight Below Average Handles- Weight Average Handles- Weight Above Average Handles- Weight Exceptional Handles- Length Handles- Length Below Average Handles- Length Average Handles- Length Above Average Handles- Length Exceptional Handles- Site Visibility with Trial or Implant Engaged Handles- Site Visibility with Trial or Implant Engaged Below Average Handles- Site Visibility with Trial or Implant Engaged Average Handles- Site Visibility with Trial or Implant Engaged Above Average Handles- Site Visibility with Trial or Implant Engaged Exceptional Bone Awl Bone Awl Below Average Bone Awl Average Bone Awl Above Average Bone Awl Exceptional Driver Driver Below Average Driver Average Driver Above Average Driver Exceptional Cover Plate Inserter Cover Plate Inserter Below Average Cover Plate Inserter Average Cover Plate Inserter Above Average Cover Plate Inserter Exceptional Slide Hammer Slide Hammer Below Average Slide Hammer Average Slide Hammer Above Average Slide Hammer Exceptional Implant Inserter Implant Inserter Below Average Implant Inserter Average Implant Inserter Above Average Implant Inserter Exceptional Mallet Mallet Below Average Mallet Average Mallet Above Average Mallet Exceptional Please explain any below average ratings. Question Title * 22. Bone Graft Yes No If yes, state the type of graft used Question Title * 23. Would you use a 35 degree Implant? Yes No Question Title * 24. Play in the implant or trial while engaged to the inserter Snug Loose Question Title * 25. Rate the implant Below Average Average Above Average Exceptional Ease of Insertion Ease of Insertion Below Average Ease of Insertion Average Ease of Insertion Above Average Ease of Insertion Exceptional Lordosis Range Lordosis Range Below Average Lordosis Range Average Lordosis Range Above Average Lordosis Range Exceptional Size of Implant Size of Implant Below Average Size of Implant Average Size of Implant Above Average Size of Implant Exceptional Other (please specify) Question Title * 26. General Implant Yes No Was the Footprint Appropriate? Was the Footprint Appropriate? Yes Was the Footprint Appropriate? No Was the Tray Presentation Helpful? Was the Tray Presentation Helpful? Yes Was the Tray Presentation Helpful? No Question Title * 27. Characterize the teeth Adequate Too Aggressive Insufficient Question Title * 28. Marker locations Ideal Should be closer to edge Should be farther from edge Question Title * 29. Any other suggestions for possible future improvements? Question Title * 30. Todays Date Date Date Question Title * 31. Your Name Submit
