Follow up to Procedure Questionnaire
Please fill out this form to help us to access your level of success with your recent procedure at Bloor Pain Specialists. We will document the information provided to help narrow down your treatment plan.
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Full Name *
Date of Birth *
Type of Procedure *
Did the procedure help? *
How long did this pain relief last for? (# of days or ongoing) *
# of days/weeks 
How would you rate your pain relief from 0-10? *
no pain relief
complete pain relief
How would you described your current level of Activity? *
How would you described your current level of Mood? *
How would you described your current level of Walking? *
How would you described your current level of Work since your procedure? (including house work) *
How would you described your current level of Sleep since your procedure? *
How would you described your current level of Relations with other people since your procedure? *
How would you described your current level of Enjoyment/Quality of Life since your procedure? *
After your procedure did you have any of the below? *
Required
Are you satisfied with the results of your procedure?
*
How satisfied are you with the results of your procedure?
*
Additional concerns post-procedure? *
Thank you for completing our questionnaire. Are you still experiencing the same pain?
*
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