Neurosurgical pain management

1. Pain relief 25% 50% 75% 100% 2. Return to Work Same job at time of injury Different job. Specify ____________________ Will you need training for this job? Yes No Have you arranged for this yet? Yes No Am retired. Do not plan to return to work 3. What family activities can you not engage in now?_________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 4. Which of these do you plan to resume if your operation is successful? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 5. If you get significant pain relief, what physical activities do you plan to resume? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 6. Do you have an attorney regarding your disability? Yes No If your answer is “yes,” what is it that your attorney is doing at this time on your behalf? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 7. Do you have an open compensation claim or lawsuit at this time regarding your disability? Yes No If your answer is “yes,” what are your plans regarding it if your operation is successful? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 8. Do you know what is the cause of your pain? Yes No If your answer is “yes,” what is your understanding for its cause? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 9. What do you plan to do if this operation or treatment is not successful in relieving a substantial part of your pain? ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 10. Please share with us your opinion of the medical care you have received to date for your pain. ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ ______________________________________________________________________________________________________