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* 1. What product did you use?

Location and Physician

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* 2. Hospital Name

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* 3. Address

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* 4. Physician Name

Patient Demographics

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* 5. Patient Gender

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* 6. Patient Age

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* 7. Patient Weight

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* 8. Patient Height

Procedure

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* 9. Segments

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* 10. Disc Removed

0% 50% 100%
i We adjusted the number you entered based on the slider’s scale.

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

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* 12. Operation Date and Time

Date / Time

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* 13. Total Operative Time (00:00)

Implants used

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* 14. Instruments used (check any used)

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* 15. Implant Length

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* 16. Implant Height

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* 17. Degree

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* 18. Width

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* 19. Use (per level)

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* 20. Bone Graft

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* 21. 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
Shavers
Box Chisels
Bone Graft Block
Slide Hammer
Implant Inserter

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* 22. Play in Implant or Trial While Engaged to Inserter

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* 23. Rate the Implant

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

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* 24. General Implant

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

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* 25. Characterize the Teeth

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* 26. Marker Locations

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* 27. Any other suggestions for possible future improvements?

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* 28. Todays Date

Date 

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* 29. Your Name

T