Please print and fill out this survey and send it to
PedicleScrew'd
P.O. Box 4473
Homosassa Springs,
Fl. 34447
or copy & paste it to an Email
katt@digitalusa.net
These results will be used for statistical purposes when writing articles in the role of an activist for PedicleScrew'd. If there is a question that you would rather not answer, please put N/A in the space given. Thank you for your participation.

I found PedicleScrew'd by: ____ Came over from the "old" list (spine.com) ____ Search Engine: ___________________________ ____ Message Board: ___________________________ ____ Web link: ________________________________ ____ Refered by: ______________________________ _______________________________________________ I live in: The USA: Give State:______________________ Outside the USA: Give Country:____________________ Age ____ Less than 16 ____ 16 to 20 ____ 21 to 30 ____ 31 to 40 ____ 41 to 50 ____ 51 to 60 ____ 61 or over Gender ____ M ____ F Personal Status ____ I live alone ____ I live with spouse ____ and children ____ Single parent with children ____ Live with significant Other ________ Age at first onset of pain ________ Age at time of first spine surgery? ________ Number of spinal surgeries done ________ Were you given "informed consent" ________ Did you know before the surgery that hardware was being implanted? Area of spine that was fused: _____________________ ___________________________________________________ Employment Status I am currently: ____ Employed full time ____ Employed part time ____ Unemployed ____ Seeking employment ____ On Permanent disability After your spinal surgery, were you able to earn: ____ More money? ____ Less money? Did you receive W/Comp? ____ Yes _____ No Social Security or SSI? ____ Yes _____ No Do you have health insurance: ____Yes ____ No Are you under the care of a pain doctor? ____Yes ____No How often do you see a pain doctor? ____ Once a week ____ Twice monthly ____ Monthly ____ Every 2-3 months ____ Every 6 months or more How often do you see your primary doctor: ____ Once a month ____ Twice a year ____ Whenever I need to Please check ALL that apply: Since fusion surgery I suffer with: ____ Back pain ____ Leg or arm pain ____ Metal taste ____ Pain at donor site (where bone was harvested) ____ Swollen glands ____ Flu-like symptoms ____ Numbness in foot or leg(s) ____ Pain down one or both arms ____ Weekness in any extremities ____ Bladder problems ____ Bowel problems ____ Sexual problems ____ Liver problems ____ Stomach problems Please check all that apply: Since fusion surgery I have developed: ____ Other disc problems ____ Degenerative Disc Disease ____ Arachnoiditis ____ Fibromyalgia ____ Insomnia ____ Arthritis ____ Increased pain ____ decrease in daily functions Check any that help with your pain ____ Back braces ____ Magnets ____ Trigger point injections ____ Over the counter medication ____ TENS Unit ____ Massages ____ Bio-feedback ____ Anti-depressants ____ Muscle relaxers ____ Anti-inflammatories ____ Opiates _____ Other: _________________________________________ Additional information or comments: ____________________________________________ ____________________________________________ ____________________________________________

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