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Please print and fill out this survey and send it to
P.O. Box 4473
Homosassa Springs,
Fl. 34447
or copy & paste it to an Email
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 (
____ Search Engine: ___________________________
____ Message Board: ___________________________
____ Web link: ________________________________
____ Refered by: ______________________________

I live in:
The USA:
Give State:______________________
Outside the USA:
Give Country:____________________

____ Less than 16
____ 16 to 20
____ 21 to 30
____ 31 to 40
____ 41 to 50
____ 51 to 60
____ 61 or over

____ 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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