Location and Physician

Question Title

* 1. Hospital Name

Question Title

* 2. Address

Question Title

* 3. Physician Name

Patient Demographics

Question Title

* 4. Patient Gender

Question Title

* 5. Patient Age

Question Title

* 6. Patient Weight

Question Title

* 7. Patient Height

Procedure

Question Title

* 8. Segments (Check all that apply if multiple levels were treated)

Question Title

* 9. Operation Date and Time

Date / Time

Question Title

* 10. Total Operative Time (00:00)

Implants used

Question Title

* 11. Instruments used (check any used)

Question Title

* 12. Kestrel Implant Size

Question Title

* 13. Screw Length 

Question Title

* 14. Rate Each Instrument

  Below Average Average Above Average Exceptional
Universal Ratchet Handle
Inserter
Bone Awl
Screw Driver
Plate Bender 
Slide Hammer
Mallet 

Question Title

* 15. Play in Implant While Engaged to Inserter

Question Title

* 16. Rate the Implant

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

Question Title

* 17. General Implant

  Yes No
Was the implant size appropriate?
Was the Tray Presentation Helpful?

Question Title

* 18. Any other suggestions for possible future improvements?

Question Title

* 19. Todays Date

Date 

Question Title

* 20. Your Name

T