Postoperative Cervical Assessment Question Title * 1. Today's date --/--/---- Date / Time Date OK Question Title * 2. Date of birth --/--/---- Date Date OK Question Title * 3. Date of your surgery? Date Date OK Question Title * 4. Have you used products containing nicotine since your last visit? Yes No If yes, specify which products OK Question Title * 5. Have you used alcohol since your last visit? Yes No If yes how many drinks do you have each week? OK Question Title * 6. Have you been diagnosed with any new illness since your last check up? No Yes If yes, please specify OK Question Title * 7. Are you currently working? Yes No OK NEXT