Orthopedics

Location Information

How may we help you?

How may we help you?

Joint Replacement Questionnaire

Blanchard Valley Hospital
1900 S. Main St.
Findlay, OH 45840

Bluffton Hospital
139 Garau St.
Bluffton, OH 45817

All fields are required

First Name:  *Last Name:  *Date of Birth:  *Email:  *Physician:  *Pre-Admission Testing Date:  *Surgery Date:  *Have you had previous joint replacement surgery?  *If yes, when and which joints? Housing Type:  *

Steps to Enter:  *Is there a hand railing?  *Bedroom on first floor?  *Bathroom on first floor?  *Type of Shower:  *Height of Toilet:  *Do you reside with anyone?  *If so, with whom? Equipment Used in the Home (or have access to): 

Do you know of someone who can help with activities such as meal preparation, grocery buying, bathing, dressing, and housekeeping while you recover from surgery?  *Do you presently receive home health services from a home care agency such as Blanchard Valley Home Health Care?  *If yes, what is the name of home health service? Do you presently receive help in your home from a social service agency such as Mobile Meals, PASSPORT or Homemakers?  *If yes, what is the name of the social service agency? Page Break When discharged, do you plan to: When discharged, if going home by car, will the car have any of the following? Any recent loss or stress?  *How do you cope with stress?  *How do you respond to pain?  *What is an acceptable pain level 1 - 10?  *Do you have any spiritual or cultural values?  *Is there anything or anyone you are afraid of?  *Any physical or mental abuse?  *Do you expect changes in life?  *Have you had treatment for emotional or behavioral issues?  *Have you had any thoughts of suicide?  *How do you learn best?  *1= Independent 2 = Assistance needed 3 = Dependent Mobility:  *Feeding:  *Transport:  *Housework  *Dressing:  *Hygiene  *Toileting:  *Meal Preparation:  *