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Post-Percutaneous Lumbar Discectomy Form

Please Fill out all fields.

Please submit your own stories about the surgery, we'd love to hear them

Name
E-mail
Today's Date(mm/dd/yy)
Date of percutaneous lumbar procedure(mm/dd/yy)
Name of Surgeon
Age
Occupation
Prior to this procedure, my symptoms were
(Example : Back Pain, Leg Pain, Numbness, Weakness)
My symptoms are now:
(Example : No Symptoms, Improved, No change, Worse)

Comments
Please Indicate Your Result:
Excellent - No Pain; No restriction of activity
Good-Occasional back of leg pain of sufficient severity to interfere with ability to work or enjoy leisure hours.
Fair- Handicapped by intermittent pain of sufficient severity to curtail or modify work or leisure activities, but improved functional capacity (not able to do usual work).
poor- No improvement or insufficient improvement to enable increase in activities; further operative intervention required.
How many days after the procedure before you returned to work?
Further surgery since percutaneous procedure?
Yes No
If so, what?
What other treatment have you needed since the procedure?
(Example: physical therapy, traction, back brace, swimming therapy, exercise therapy, injection, pills for pain, pills for muscle spasm, pills for sleep)
My authorization is given for this form to be read by potential discectomy patients.
Yes No
My authorization is given for my phone number to be given out to potential discectomy patients to call me for reference.
Yes No
Telephone Number

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Symptoms
1.Sciatica;leg pain

2.Back Pain
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