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

Procedure

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

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* 9. Disc Space Description (Check all that apply)

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* 10. Operation Date and Time

Date / Time

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* 11. Total Operative Time (00:00)

Implants used

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* 12. Instruments used (check any used)

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* 13. Implant Length

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* 14. Implant Height

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* 15. Width

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* 16. I found the graft window to be..

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* 17. Bone Graft

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* 18. 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 Graft Block
Implant Inserter- Size of Knob

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* 19. Play in Implant While Engaged to Inserter

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* 20. Rate the Implant

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

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* 21. General Implant

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

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* 22. Characterize the Teeth

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* 23. Marker Locations

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* 24. Any other suggestions for possible future improvements?

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* 25. Todays Date

Date 

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* 26. Your Name

T