Jasmit Brar - Reston - ReActiv8 Questionnaire

1
What's your full name?* This field is required.
First Name
Last Name
2
What's your Date of Birth?* This field is required.
Date
Year
Month
Day
3
Does your low back pain radiate to your leg?* This field is required.
YESNO
4
Is your pain more noticeable in your back or in your leg?* This field is required.
BACKLEG
5
How long has your low back pain lasted?* This field is required.
Less than 3 months
3 to 6 months
6 months to a year
More than 1 year
6
Have you tried any of the following treatments?* This field is required.(Please select all that apply.)
Prescription medication
Physical therapy
Injections, ablations (RFA), or other interventional procedures
All of the above
7
Have you had back surgery?* This field is required.
YESNO
8
What type of back surgery(s) have you had?* This field is required.Please select all that apply.
Lumbar spinal fusion
Lumbar laminectomy
Microdiscectomy
Hemilaminectomy
I do not know what type of surgery I've had.
9
Does your back ever feel like it is unstable?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
10
Do you get surprised by sudden pain or spasms when you do mild back movements or light tasks?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
11
Do you have problems with activities such as brushing teeth over the sink, washing dishes, or unloading dishwasher?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
12
Does it feel like your back is getting tired or painful the longer you maintain a position (e.g. standing, sitting, etc.)?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
13
Do you tend to support yourself with your arms while standing, sitting, or performing light, small movement tasks?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
14
Do backrests and back braces help when sitting or standing for long periods?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
15
Does your back pain keep you from bending?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
16
Does your back pain keep you from lifting?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
17
Does your back pain keep you from twisting?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
18
Does your back pain keep you from prolonged sitting?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
19
Does your back pain keep you from prolonged standing?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
20
Does your back pain keep you from walking?* This field is required.
Please Select
Please Select
0 ("Never")
1
2
3
4
5 ("Always")
21
Are you employed?* This field is required.
YESNO
22
Are you retired?* This field is required.
YESNO
23
Have you ever missed work due to your back pain?* This field is required.
YESNO
24
In a one-month (30 days) period, how many days have you missed?* This field is required.
1 day
2-3 days
3-4 days
Greater than 4 days
25
Would you like to reduce or discontinue your pain medication?* This field is required.
Yes
No
Neutral
26
Would you consider an implant if it could help restore function and decrease pain in your back?* This field is required.
YESNO
27
I feel my back pain is being properly controlled with my current treatment plan.* This field is required.
True
False
Neutral
28
How interested are you in learning about a new implantable treatment for your low back pain?* This field is required.
High interest
Medium interest
Low interest
I'm not sure
I'm not interested
29
I authorize Sure Med Compliance to disclose the information I’ve provided in this form to my pain management clinic for the purpose of discussing Mainstay Medical's ReActiv8 procedure. I agree to be contacted regarding this inquiry. I understand that I can revoke this authorization at any time by providing written notice to my pain management clinic. This authorization expires one year from submission.* This field is required.
I agree.
30
What is your phone number?* This field is required.
Please enter a valid phone number.
31
What is your email address?* This field is required.
example@example.com
32
Score
Should be Empty: