Joint Replacement Questionnaire

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Joint Replacement Questionnaire

Are you a candidate for Joint Replacement Surgery?

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

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* denotes required field

Are you experiencing pain in your knee, hip or groin?

Yes No

Please select one option

Is pain limiting your activities or has it caused you to change your everyday routine?

Yes No

Please select one option

Does pain or discomfort sometimes require medication stronger than Aspirin or Tylenol?

Yes No

Please select one option

Has medication stopped working?

Yes No

Please select one option

Do symptoms in your affected joint(s) hurt 4 or more days per week?

Yes No

Please select one option

Do you have pain climbing or descending the stairs?

Yes No

Please select one option

Does pain force you to stop when walking more than two or three blocks?

Yes No

Please select one option

Do you ever use walking aids, such as a cane or walker, to assist you with walking?

Yes No

Please select one option

Do you walk with a moderate limp?

Yes No

Please select one option

Do you feel pain when you are lying or sitting down?

Yes No

Please select one option

Does pain make it difficult to sleep at night?

Yes No

Please select one option

Does your knee or hip sometimes give out when you are physically active?

Yes No

Please select one option

Do you have trouble putting on your shoes and socks?

Yes No

Please select one option

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