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. Operation Date and Time

Date / Time

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* 10. Total Operative Time (00:00)

Product

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* 11. Please rate how well you agree with the following statements.

  Strongly Disagree Disagree Agree Strongly Agree
The available sizes of the implants were appropriate.
The Implant/Instrument interface is adequate to install the system.
The instrument length and thickness did not reduce visibility when installing.
The overall instrument design was appropriate for OPEN SURGERY technique.
The overall instrument design was appropriate for MIS SURGERY technique.
I like the tactile feel of the instruments.
I found the pedicle screw easy to work with.
The angle of the polyaxial screw was appropriate.
The purchase of screw thread was sufficient and strong.
The placement of the cross-link was appropriate and free of problems giving a good range of motion.
I found the cross link inserter useful.
I found the cross link locking system useful. (set screw alignment, ease of use)
I liked the tactile feel of the implants.
The set screw/locking cap and final torque on the implant were ideal.
I liked the function and usefulness of the pistol grip rod persuader.
I liked the K-wire length and function.
I found the surgical technique guide to be useful.
Overall, I was satisfied with the Excella II Spinal System.

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* 12. Any other suggestions for possible future improvements?

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* 13. Todays Date

Date 

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* 14. Your Name

T