Rose Institute for Joint Replacement

Patient Survey - Hip or Knee

Please take a few minutes to fill out the following form. Your response will be sent to our Institute and someone will contact you shortly.

Name
Email
Tel #
Are you experiencing pain in your Knee, Hip or Groin?		Yes No
If yes, which area(s) is affected?
Is the pain limiting or causing you to change your work habits?		Yes No
Is the pain limiting or causing you to change your everyday activities?		Yes No
Does the pain or discomfort sometimes require medication stronger than Aspirin or Tylenol?		Yes No
Is this medication still working?		Yes No
Do the symptoms in your affected joint(s) hurt 4 or more days per week?		Yes No
Do you have pain climbing or descending stairs?		Yes No
Does pain force you to stop when walking more than two or three blocks?		Yes No
Do you ever use walking aids such as a cane or walker to assist you with walking?		Yes No
Do you walk with a moderate limp?		Yes No
Do you feel pain when you are lying or sitting down?		Yes No
Does pain make it difficult to sleep at night?		Yes No
Does your knee or hip sometimes give out when you are physically active?		Yes No