**St.** **Francis.** -StopTm Stud **Medical Technologies, Inc** Zurich
Claudication Questionnair

Case Report Form Z( Page 1 of 3)

To be filled out by the patient - Social Security Number

Patient:

***Last First** MI* :

Date : / / Investigator:

***Last First** MI*

Please Read: This survey has been designed to give the doctor
information as to how your back pain has affected your ability to manage
in everyday life. Please answer every section, and mark in each section
only the one box which applies to you. We realize you may consider that
two of the statements in any one section relate to you, but please just
mark the box *which* most closely describes your problem.

PARTl:\~Symptom Severity Scale

In the last month, how would you describe;

Question 1. The pain you have had on average including the pain in you
back, buttocks and pain that goes down your legs?

[F^-^1]{.underline} 1 None F1 2 Mild \[:\] 3 Moderate
[\[-\]]{.underline} 4 Severe \[15 Very Severe

Question 2. How often have you had back, buttock, or leg pain?
[\[^-^1]{.underline}1 Less than once a week

F1 2 At least once a week

0 3 Everyday, for at least a few minutes F1 4 Everyday, for most of the
day

0 5 Every minute of the day

Question 3. The pain in your back or buttocks?

F1 1 None U 2 Mild 0 3 Moderate \[14 Severe 0 5 Very Severe

Question 4. The pain in your legs or feet?

[\[-\]]{.underline} 1 None \[12 Mild \[\] 3 Moderate F\] 4 Severe 0 5
Very Severe

Question 5. Numbness or tingling in your legs or feet?

El 1 None \[\] 2 Mild 0 3 Moderate El 4 Severe R 5 Very Severe

Question 6. Weakness in your legs or feet?

0 1 None 0 2 Mild El 3 Moderate 0 4 Severe \[:\] 5 Very Severe

Question 7. Problems with your balance? F\] 1 No, I have had no problems
with balance [F^-^1]{.underline} 3 Yes, sometimes I feel my balance is
off, or that I am not sure footed F\] 5 Yes, often I feel my balance is
off, or hat I am not sure footed

***1900* Bates, Avenue, Concord, CA *94520 (925) 969-0471***

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St. **Francis** Stud x-Stop\"\"

**Medical Technologies, Inc.** Zurich Claudication Questionnair^,^ Case
Report Form Z\< Page 2 of

Patient: - Social Security Number: / /

> **Last First**

Date : I / Investigator:

**Last First MI**

PART 2: Physical Function Scale

In the last month, on a typical day;

Question 8. How far have you been able to walk? F1 1 Over 2 miles

\[\] 2 Over 2 blocks, but less than two miles 3 Over 50 feet, but less
than 2 blocks F1 4 Less then 50 feet

Question 9. Have you taken walks outdoors or in the malls? (\~ 1 Yes,
comfortably

2 Yes, but sometimes with pain [F\]]{.underline} 3 Yes, but always with
pain \[14 No

Question 10. Have you been shopping for groceries or other items?
[F\]]{.underline} 1 Yes, comfortably

F1 2 Yes, but sometimes with pain [F\]]{.underline} 3 Yes, but always
with pain F\]4 No

Question 11. Have you walked around the different rooms in your house or
apartment? \[\] 1 Yes, comfortably

0 2 Yes, but sometimes with pain F\] 3 Yes, but always with pain \[:14
No

Question 12. Have you walked from your bedroom to the bathroom? \[\] 1
Yes, comfortably

F1 2 Yes, but sometimes with pain \[\] 3 Yes, but always with pain n 4
No

**1900 Bates, Avenue, Concord, CA 94520 (925) 969-0471**

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height="0.20694444444444443in"}

St. **Francis**

**Medical Technologies, Inc.**

> X-StopTm Stud
>
> Zurich Claudication Quesfonnair^,^
>
> Case Report Form Z( Page 3 of

Patient:

> Last First

Date : J / Investigator:

Social Security Number: J

Last First Mi

Part 3; Satisfaction Scale

How satisfied are you with:

Question 13. The overall result of back operation? n 1 Very satisfied

F\] 2 Somewhat satisfied n 3 Somewhat dissatisfied F1 4 Very
dissatisfied

Question 14. Relief of pain following the operation? n 1 Very satisfied

El 2 Somewhat satisfied Q 3 Somewhat dissatisfied F\] 4 Very
dissatisfied

Question 15. Your ability to walk following the operation? F1 1Very
satisfied

F1 2 Somewhat satisfied F1 3 Somewhat dissatisfied F1 4 Very
dissatisfied

Question 16. Your ability to do 0 1 Very satisfied

F\] 2 Somewhat satisfied F1 3 Somewhat dissatisfied F\] 4 Very
dissatisfied

housework, yard work, or job following the

operation?

Question 17. Your strength in the thighs, legs and feet? F\] 1 Very
satisfied

El 2 Somewhat satisfied Q 3 Somewhat dissatisfied \[\] 4 Very
dissatisfied

Question 18. Your balance, or steadiness on your feet? 0 1 Very
satisfied

El 2 Somewhat satisfied F\] 3 Somewhat dissatisfied 0 4 Very
dissatisfied

Printed name Patient Signature

Today\'s date /-1.

1900 Bates, Avenue, Concord, CA 94520 (925) 969-0471

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height="0.21041666666666667in"}