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Dr. Steven Chudik - Pre-surgery Survey
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* Indicates required question
What is your Patient ID number? (it is found on the text you received.)
*
Your answer
On which body part is your surgery?
*
Choose
Shoulder
Upper arm
Elbow
Forearm
Knee
Leg
Ankle
Foot
Is the surgery on your Right Side or Left Side
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Choose
Right Side
Left Side
On a scale of 0 to 100, please select the number to rate the function of your injured body part at this time with 100 being normal.
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Choose
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On a scale of 1 to 10, please please select a number to rate the pain of your injured body part at this time with zero representing "No pain" and 10 representing the "worst pain you've ever felt or could imagine.
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Choose
0
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