post-procedure office visit (1 month)

Site

Patient Number

Please enter in three digit format (e.g., 001, 002, ..., 025)

Is this an original or revised submission?

Original

Revised

Name of the Person Entering Data into this CRF

First Name

Last Name

Date of Post-Procedure Visit (1 Month)

YYYY

Return to Normal Activity

Yes

Date of Return to Normal Activity

YYYY

Return to Work

Yes

Date of Return to Work

YYYY

Please describe any notable events during the previous 1 month.

Attestation

I approve the data entered into this CRF and attest to its accuracy.

Date of Completion

YYYY