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. Surgery for this level

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* 9. Fusion Procedure

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* 10. Screw Placement Technique

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* 11. Operation Date and Time

Date / Time

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* 12. Total Operative Time (00:00)

Implants used

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* 13. Screw Diameter

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* 14. Screw Length

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* 15. Rod Length (35mm-130mm in 5mm increments)

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* 16. Rod

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* 17. Rod Style

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* 18. Rate Each Instrument

  Below Average Average Above Average Exceptional
Jamshidi
K-Wire
Dilators
Taps
Pedicle Screw Driver
Snap Rings (if used)
Snap Sleeves (if used)
Dissector/Letter Opener
Percutaneous Rod Holder
Pituitary-Style Rod Holder
Kerrison-Style Rod Holder
Rod Calipers
Stab-and-Grab Drivers for Locking Cap
3.5-to-1 speed Driver
Anti-Torque (Low-profile style, if used)
Compressor/Distractor
Tab Remover

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* 19. Rate Each Implant

  Below Average Average Above Average Exceptional
Length of Break-Away Towers
Ease of Placing Screws
Range of Screw Sizes Offered
Range of Rod Lengths Offered
Ease of Rod Placement
Ease of Locking Cap Placement
Range of Reduction
Ease of Rod Reduction
Overall Satisfaction with the System

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* 20. Any other suggestions for possible future improvements?

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* 21. Todays Date

Date 

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* 22. Your Name

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