This takes about 5–8 minutes. Your answers help us track your progress and improve your care.
Patient Identifier
To protect your privacy, we only collect your MRN (patient ID number). Your care team will match your scores to your chart internally. No name or date of birth is stored.
Your MRN is on your visit summary, appointment reminder, or you can ask the front desk.
Visit Timepoint
📋
Pre-Op
Baseline
📅
3 Months
Post-op
📅
6 Months
Post-op
🏆
1 Year
Post-op
📆
2 Years
Post-op
📆
3+ Years
Post-op
Section 1 of 5 — Pain Scores
Rate your pain.
Select a number for each area. 0 means no pain, 10 means the worst pain imaginable.
Numeric Rating Scale (NRS) — Last 7 Days
Section 2 of 5 — Back & Leg Function
Oswestry Disability Index
These questions help us understand how back or leg pain affects your daily activities. Select one answer per section.
Section 3 of 5 — Neck & Arm Function
Neck Disability Index
These questions help us understand how neck or arm pain affects your daily life. Select one answer per section.
Section 4 of 5 — General Health
Overall Health & Satisfaction
A few questions about your general health and your care experience.
PROMIS Global Health — v1.2
Patient Satisfaction
Overall, how satisfied are you with the care you received at miiSpine?
Very dissatisfiedVery satisfied
Section 5 of 5 — Review
Almost done.
Review your scores before submitting. Your data is sent securely to your care team.
⚙️ Setup required: Paste your Microsoft Power Automate HTTP trigger URL into WEBHOOK_URL at the top of the HTML file to enable data collection to Excel on SharePoint. See setup instructions in the file comments.
✅
Thank you.
Your responses have been recorded and sent to the miiSpine care team. We'll review your scores before your appointment.