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Treatment Questionnaire
Please take a few minutes to print this document then fill out the
questions. This is
optional and all information is confidential.
Please send your completed response to:
Orthopaedic Associates 75 Pringle Way #912 Reno, NV 89502
You may also bring this form to your next visit and drop off at
check-in
A. For your last office visit:
B. For your Treatment
- 1. Who was your treating doctor- Webster Preston Davis
(circle one)
- 2. Did you eventually have surgery- yes no (circle one) NO-SKIP
TO 12
- 3. How long after your first office visit did you have surgery- <1
wk 1-2wks
- 2-6wks <3mo 3-6mo >6mo (circle
one)
- 4. Did you have Physical Therapy BEFORE surgery- yes no
(circle one)
- 5. Did you have surgery to reduce pain- yes no (circle one)
-
a. Please rate your pain before treatment: 0 none to 10 most
-
0
1 2 3 4 5 6 7 8 9
10
- b. Please rate your pain at your final office visit: 0 none to 10
-
0
1 2 3 4 5 6 7 8 9
- 6. Did you have surgery to improve function i.e. ability to lift, ability to
walk,
- ability to work or play sports- yes no (circle one)
- a. Please rate your function before treatment: 0 worst to 10 best-
-
0
1 2 3 4 5 6 7 8 9 10
(circle one)
- b. Please rate your function at your final office visit: 0 to 10-
-
0
1 2 3 4 5 6 7 8 9
10 (circle one)
- 7. Were you satisfied with your results of treatment- yes
no (circle one)
- 8. Would you have surgery again for the same problem- yes no
(circle one)
- 9. What surgery did you have: Fracture (broken bone)
surgery
- Arthroscopic surgery Spine
(fusion or disc) surgery
- Joint replacement
surgery Hand surgery Foot
surgery
- (circle one or write in the name of your
procedure here)_________________________________________________________________
-
10. Do you feel an adequate period of non-surgical treatment was tried
prior
-
to surgery- yes no (circle one)
-
11. Please rate your post-operative Physical Therapy care:
-
1 least to 5 most
helpful-
1 2 3 4 5 (circle one)
- 12. Please give an overall rating for your care at Orthopaedic Associates: 1
least
- to 5 best- 1 2 3 4 5 (circle one)
Name
(optional)_____________________________________________________________________
Dates of treatment (mo/yr)___________________________________
Comments/suggestions__________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
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