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Virtua Joint Replacement Institute

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Joint Replacement Questionnaire

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Virtua Joint Replacement Institute
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Joint Replacement Institute

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Are you a candidate for Joint Replacement Surgery?

Please take a few moments to fill out the following online form. Thank you.

Read our Privacy Statement.

Are you experiencing pain in your knee, hip or groin?	YesNo
Is pain limiting your activities or has it caused you to change your everyday routine?	YesNo
Does pain or discomfort sometimes require medication stronger than Aspirin or Tylenol?	YesNo
Has medication stopped working?	YesNo
Do symptoms in your affected joint(s) hurt 4 or more days per week?	YesNo
Do you have pain climbing or descending the stairs?	YesNo
Does pain force you to stop when walking more than two or three blocks?	YesNo
Do you ever use walking aids, such as a cane or walker, to assist you with walking?	YesNo
Do you walk with a moderate limp?	YesNo
Do you feel pain when you are lying or sitting down?	YesNo
Does pain make it difficult to sleep at night?	YesNo
Does your knee or hip sometimes give out when you are physically active?	YesNo
Do you have trouble putting on your shoes and socks?	YesNo

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