Location and Physician

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* 1. Hospital Name

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* 2. Address

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* 3. Physician Name

Patient Demographics

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* 4. Patient Gender

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* 5. Patient Age

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* 6. Patient Weight

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* 7. Patient Height

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* 8. Indication

Procedure

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* 9. Segments

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* 10. Disc Removed

0% 50% 100%
i We adjusted the number you entered based on the slider’s scale.

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* 11. Disc space description (Check all that apply)

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* 12. Operation date and time

Date / Time

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* 13. Total operative time (00:00)

Implants used

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* 14. Instruments used (check any used)

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* 15. Implant height

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* 16. Screw length

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* 17. Degree

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* 18. Width

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* 19. Cap size

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* 20. Use (per level)

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* 21. Rate each instrument

  Below Average Average Above Average Exceptional
Trials- Ease of Insertion
Trials- Removal from Disc Space
Trials- Overall Design
Handles- Weight
Handles- Length
Handles- Site Visibility with Trial or Implant Engaged
Bone Awl
Driver
Cover Plate Inserter
Slide Hammer
Implant Inserter
Mallet

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* 22. Bone Graft

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* 23. Would you use a 35 degree Implant?

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* 24. Play in the implant or trial while engaged to the inserter

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* 25. Rate the implant

  Below Average Average Above Average Exceptional
Ease of Insertion
Lordosis Range
Size of Implant

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* 26. General Implant

  Yes No
Was the Footprint Appropriate?
Was the Tray Presentation Helpful?

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* 27. Characterize the teeth

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* 28. Marker locations

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* 29. Any other suggestions for possible future improvements?

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* 30. Todays Date

Date 

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* 31. Your Name

T