Postoperative Lumbar Assessment

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* 1. Today's date --/--/----

Date / Time

Date

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* 2. Date of Birth --/--/----

Date / Time

Date

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* 3. Date of your surgery --/--/----

Date / Time

Date

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* 4. Have you used products containing nicotine since your last visit?

Yes

No

If yes, specify which products

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* 5. Have you used alcohol since your last visit?

Yes

No

If yes, how many drinks do you have each week?

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* 6. Have you been diagnosed with any new illness since your last check up?

No

Yes

If yes, please specify

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* 7. Are you currently working?

Yes

No