Hip Satisfaction

Today’s Date
 

Last Name

First Name

Date of Birth
 

Date of Surgery
 

Hip (Left or Right)

Which Time Period Are You Reporting?

Were you readmitted after surgery?

How many nights were you in the hospital?

   
   
 

If more than 3, then how many?

Was your surgery free of complications?

 
 

If you think you had a "complication"- what was it?

How important are recreation and exercise to you?

   
   
 

Did your hip replacement allow you to resume all or most of your activities?

 
 

What is your employment status?

   
   
 

If your employment is not mentioned above, please type it in here

How many weeks did it take for you to return to your employment or other activities?

     
     
   

On a scale of 1-10, how important is it to you that your surgeon used minimally invasive techniques?

On a scale of 1-10, how important is it to you that your surgeon used computer navigation technique?

Were your expectations from your knee replacement met?

 
 

If no, what could have been done better to meet your expectations?

On a scale of 1-10, how likely are you to recommend your surgeon to family or friends?

On a scale of 1-10, how satisfied are you with your surgeons technical skills as a surgeon?

Powered by SwiftPath, LLC online database.