Preoperative Lumbar Assessment Question Title * 1. Today's date --/--/---- Date Date OK Question Title * 2. Date of Birth --/--/---- Date / Time Date OK Question Title * 3. Gender Male Female Other OK Question Title * 4. Marital status Married Divorced Separated Widowed Single De Facto OK Question Title * 5. Race Caucasian Asian Aboriginal / Native Descent Other OK Question Title * 6. Highest Level of Education Primary Grade 10 Grade 12 Diploma/TAFE Tertiary OK Question Title * 7. What was your work status prior to your illness or injury? Working (including homemaker or self-employed) Unemployed or student - not working Retired due to back problem On paid leave / disability due to current back problem Retired not due to back problem Other (please specify) OK NEXT