Spinal Cord Stimulator Psychological Evaluation

[Your Company Name]

Patient Information:

Name
Date of Birth
Gender
Contact Number
Email Address
Referring Physician
Date of Referral

Introduction

This evaluation aims to assess a patient's psychological readiness for the Spinal Cord Stimulator procedure. This form is an essential tool for ensuring patients have realistic expectations and are prepared for potential lifestyle changes.

Evaluation Overview

Through a series of tailored psychological assessment tools and questions, we aim to ensure a comprehensive understanding of the patient's mindset and expectations. This process plays a critical role in patient satisfaction and success after the Spinal Cord Stimulator procedure.

Evaluation Criteria

The evaluation criteria are categorized into three broad areas:
1) Patient's Understanding and Expectations
2) Patient's Mental and Emotional Stability
3) Patient's Coping Strategies and Support System.

Criteria	Description	Rating (1-5)
Patient's Understanding and Expectations	This criterion measures the patient's understanding of the procedure, the benefits, potential risks, and realistic expectations of pain relief post-procedure.
Patient's Mental and Emotional Stability	This criterion assesses the patient's mental health condition and emotional stability to undergo the procedure and cope with the outcomes and lifestyle adaptations.
Patient's Coping Strategies and Support System	This criterion evaluates the patient's ability to manage stress and their level of support from family and friends to handle recovery and lifestyle changes.

Score Guide:
1 = Very Poor
2 = Poor
3 = Average
4 = Good
5 = Excellent

Additional Comments and Notes

Evaluation Templates @ Template.net