0844 589 2020/3030
0203 973 8810
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19 Harley St, London, W1G 9QJ, UK
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Home
Appointment
Treatments
What we do
Spinal Assessments
Spinal Stenosis
Back Pain
Diagnostics
Lumbar Slipped Disc
Sciatica
Lumbago
Spinal Disc Problems
Sacroiliac Joint Disorders
Spine Cancer
Laser Disc Surgery
Percutaneous Laser Discectomy
keyhole spinal surgery Or Minimally invasive
Keyhole Spinal Surgery
Spinal Endoscopic Surgery
Open Spinal Surgery
Lumbar Decompression
Anterior Cervical Discectomy + Fusion
Lumbar Fusion Surgery Treatment
Balloon Kyphoplasty Vertebroplasty
Disc Replacement Surgery Treatment
Spinal Epiduroscopy Surgery
Spinal Ozone Therapy
Spinal Injections
Facet Joint Injections Blocks
Lumbar Caudal Epidural
Physical Therapy
Non-Invasive Pain Management
Spinal Tumours Treatment
Advanced Spine Scanning Technology
About Us
About Us
Clinic Prices
Video Gallery
London Spine Unit Reviews
Submit a review
Contact Us
Book an Appointment
Upload your MRI for Review
Clinical Details Form
Book a Second Opinion
Our Clinics
Harley Street London Clinic
Islamabad Spinal Clinic
The Harley Street Hospital
Our Team
Mr Mo Akmal MBBS BSc (Hons) MD FRCS (Orth)
Mr Mo Akmal Profile
Mr Masood Shafafy MBBS FRCS(Orth)
Mr Masood Shafafy CV
Mr Ahmed Hussein FRCS (Neur.Surg)
Mr Reza Mobasheri FRCS(Orth)
Mr Mohammed Ahmed FRCS
Therapists
APPI – Wimbledon
Boost Physio
Carla Pozner M.Ost, ND, DO
Central Health – Chelsea
Central Health – Farringdon
Central Health – Chancery Lane
Central Health – Highgate
Central Health – St Johns Wood
Injury Rehab
Onebody Clinic
North West London Physio & Treatment Centre
Physio Ed
Testimonials
Submit Testimonial
Spinal Injection Testimonials
Spinal Surgery Testimonials
Resources
Published Research Articles
Information Leaflets
Spinal Injections Information Booklet
Percutaneous Laser Disc Decompression Information Booklet
Lumbar Discectomy Decompression Information Booklet
Lumbar Decompression + Stabilisation Information Booklet
Balloon Kyphoplasty Information Booklet
Lumbar Fusion Surgery Information Booklet
Consent Forms
Consent Form Cervical Spine Surgery
Lumbar Spine Surgery Consent Form
Laser Spine Surgery Consent Form
Menu
Home
Appointment
Treatments
What we do
Spinal Assessments
Spinal Stenosis
Back Pain
Diagnostics
Lumbar Slipped Disc
Sciatica
Lumbago
Spinal Disc Problems
Sacroiliac Joint Disorders
Spine Cancer
Laser Disc Surgery
Percutaneous Laser Discectomy
keyhole spinal surgery Or Minimally invasive
Keyhole Spinal Surgery
Spinal Endoscopic Surgery
Open Spinal Surgery
Lumbar Decompression
Anterior Cervical Discectomy + Fusion
Lumbar Fusion Surgery Treatment
Balloon Kyphoplasty Vertebroplasty
Disc Replacement Surgery Treatment
Spinal Epiduroscopy Surgery
Spinal Ozone Therapy
Spinal Injections
Facet Joint Injections Blocks
Lumbar Caudal Epidural
Physical Therapy
Non-Invasive Pain Management
Spinal Tumours Treatment
Advanced Spine Scanning Technology
About Us
About Us
Clinic Prices
Video Gallery
London Spine Unit Reviews
Submit a review
Contact Us
Book an Appointment
Upload your MRI for Review
Clinical Details Form
Book a Second Opinion
Our Clinics
Harley Street London Clinic
Islamabad Spinal Clinic
The Harley Street Hospital
Our Team
Mr Mo Akmal MBBS BSc (Hons) MD FRCS (Orth)
Mr Mo Akmal Profile
Mr Masood Shafafy MBBS FRCS(Orth)
Mr Masood Shafafy CV
Mr Ahmed Hussein FRCS (Neur.Surg)
Mr Reza Mobasheri FRCS(Orth)
Mr Mohammed Ahmed FRCS
Therapists
APPI – Wimbledon
Boost Physio
Carla Pozner M.Ost, ND, DO
Central Health – Chelsea
Central Health – Farringdon
Central Health – Chancery Lane
Central Health – Highgate
Central Health – St Johns Wood
Injury Rehab
Onebody Clinic
North West London Physio & Treatment Centre
Physio Ed
Testimonials
Submit Testimonial
Spinal Injection Testimonials
Spinal Surgery Testimonials
Resources
Published Research Articles
Information Leaflets
Spinal Injections Information Booklet
Percutaneous Laser Disc Decompression Information Booklet
Lumbar Discectomy Decompression Information Booklet
Lumbar Decompression + Stabilisation Information Booklet
Balloon Kyphoplasty Information Booklet
Lumbar Fusion Surgery Information Booklet
Consent Forms
Consent Form Cervical Spine Surgery
Lumbar Spine Surgery Consent Form
Laser Spine Surgery Consent Form
Appointment
Menu
Home
Appointment
Treatments
What we do
Spinal Assessments
Spinal Stenosis
Back Pain
Diagnostics
Lumbar Slipped Disc
Sciatica
Lumbago
Spinal Disc Problems
Sacroiliac Joint Disorders
Spine Cancer
Laser Disc Surgery
Percutaneous Laser Discectomy
keyhole spinal surgery Or Minimally invasive
Keyhole Spinal Surgery
Spinal Endoscopic Surgery
Open Spinal Surgery
Lumbar Decompression
Anterior Cervical Discectomy + Fusion
Lumbar Fusion Surgery Treatment
Balloon Kyphoplasty Vertebroplasty
Disc Replacement Surgery Treatment
Spinal Epiduroscopy Surgery
Spinal Ozone Therapy
Spinal Injections
Facet Joint Injections Blocks
Lumbar Caudal Epidural
Physical Therapy
Non-Invasive Pain Management
Spinal Tumours Treatment
Advanced Spine Scanning Technology
About Us
About Us
Clinic Prices
Video Gallery
London Spine Unit Reviews
Submit a review
Contact Us
Book an Appointment
Upload your MRI for Review
Clinical Details Form
Book a Second Opinion
Our Clinics
Harley Street London Clinic
Islamabad Spinal Clinic
The Harley Street Hospital
Our Team
Mr Mo Akmal MBBS BSc (Hons) MD FRCS (Orth)
Mr Mo Akmal Profile
Mr Masood Shafafy MBBS FRCS(Orth)
Mr Masood Shafafy CV
Mr Ahmed Hussein FRCS (Neur.Surg)
Mr Reza Mobasheri FRCS(Orth)
Mr Mohammed Ahmed FRCS
Therapists
APPI – Wimbledon
Boost Physio
Carla Pozner M.Ost, ND, DO
Central Health – Chelsea
Central Health – Farringdon
Central Health – Chancery Lane
Central Health – Highgate
Central Health – St Johns Wood
Injury Rehab
Onebody Clinic
North West London Physio & Treatment Centre
Physio Ed
Testimonials
Submit Testimonial
Spinal Injection Testimonials
Spinal Surgery Testimonials
Resources
Published Research Articles
Information Leaflets
Spinal Injections Information Booklet
Percutaneous Laser Disc Decompression Information Booklet
Lumbar Discectomy Decompression Information Booklet
Lumbar Decompression + Stabilisation Information Booklet
Balloon Kyphoplasty Information Booklet
Lumbar Fusion Surgery Information Booklet
Consent Forms
Consent Form Cervical Spine Surgery
Lumbar Spine Surgery Consent Form
Laser Spine Surgery Consent Form
19 Harley St, London, W1G 9QJ, UK
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Privacy Policy
Privacy Policy
Procedure Outcomes
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theatreaptindex
Date
DD slash MM slash YYYY
Time
:
Your Name
Lumbar Spine
Back or Wound Pain
(Required)
No Pain
Mild Pain
Moderate Pain
Fairly Severe Pain
Very Severe Pain
Worst Possible Pain
Leg or Foot Pain
(Required)
No Pain
Mild Pain
Moderate Pain
Fairly Severe Pain
Very Severe Pain
Worst Pain Possible
Numbness in Legs/Feet
(Required)
No Numbness
Mild Numbness
Moderate Numbness
Fairly Severe Numbness
Very Severe Numbness
Completely Numb
Weakness in Legs/Feet
(Required)
Full Strength
Mild Weakness
Moderate Weakness
Fairly Severe Weakness
Very Severe Weakness
No Movement at All
Passing Urine
(Required)
Normal Function
Mild Difficulty
Moderate Difficulty
Fairly Severe Difficulty
Very Severe Difficulty
No Control of Urine
Opening Bowels
(Required)
Normal Function
Mild Difficulty
Moderate Difficulty
Fairly Severe Difficulty
Very Severe Difficulty
No Control of Bowels
Recovery ?
(Required)
Much Better
Better
As Expected
Slightly Worse
Worse
Much Worse
Functional Score
Personal Care (Washing, Dressing etc.)
(Required)
I can look after myself normally without causing extra pain.
I can look after myself normally, but it causes extra pain.
It is painful to look after myself and i am slow and careful
I need some help but can manage most of my personal care.
I need help every day in most aspects of self-care
I do not get dressed, I washed with difficulty and stay in bed.
Lifting
(Required)
I can lift heavy weights without extra pain.
I can lift heavy weights but it gives me extra pain.
Pain prevents me lifting heavy weights off the floor, but I can manage if they are conveniently placed, for example on a table
Pain prevents me from lifting heavy weights but I can manage light to medium weights if they are conveniently positioned
I can only lift very light weights
I cannot lift or carry anything
Walking
(Required)
Pain does not prevent me walking any distance.
Pain prevents me from walking more than 1 mile.
Pain prevents me from walking more than 1/2 mile.
Pain prevents me from walking more than 100 yards.
I can only walk using a stick or crutches.
I am in bed most of the time.
Sitting
(Required)
I can sit in any chair as long as I like.
I can only sit in my favourite chair as long as I like.
Pain prevents me sitting more than one hour.
Pain prevents me from sitting more than 30 minutes.
Pain prevents me from sitting more than 10 minutes.
Pain prevents me from sitting at all.
Standing
(Required)
I can stand as long as I want without extra pain.
I can stand as long as I want but it gives me extra pain.
Pain prevents me from standing for more than 1 hour
Pain prevents me from standing for more than 30 minutes.
Pain prevents me from standing for more than 10 minutes.
Pain prevents me from standing at all.
Sleeping
(Required)
My sleep is never disturbed by pain.
My sleep is occasionally disturbed by pain.
Because of pain I have less than 6 hours sleep.
Because of pain I have less than 4 hours sleep.
Because of pain I have less than 2 hours sleep.
Pain prevents me from sleeping at all.
Sex Life (if Applicable)
My sex life is normal and causes no extra pain.
My sex life is normal but causes some extra pain.
My sex life is nearly normal but is very painful.
My sex life is severely restricted by pain.
My sex life is nearly absent because of pain.
Pain prevents any sex life at all.
Social Life
(Required)
My social life is normal and gives me no extra pain.
My social life is normal but increases the degree of pain.
Pain has no significant effect on my social life apart from limiting my more energetic interests eg, sport.
Pain has restricted my social life and I do not go out as often.
Pain has restricted my social life to my home.
I have no social life because of pain.
Travelling
(Required)
I can travel anywhere without pain.
I can travel anywhere but it gives me extra pain.
Pain is bad but I manage journeys over two hours.
Pain restricts me to journeys of less than one hour.
Pain restricts me to short necessary journeys under 30 minutes.
Pain prevents me from travelling except to receive treatment.
Notes
Please add any additiional comments here
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