First Name Last Name Email Phone Address Address Address 2 City State - None -AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle East)Armed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederated States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Date of surgery, if known. Name of hospital where you are having your surgery. Name of surgeon performing your shoulder replacement. Name of your support person or coach. Quiz questions I should shower with chlorhexidine gluconate (CHG) before my surgery.? - Select -TrueFalse Unless instructed otherwise, I should eat or drink after midnight the day before surgery. - Select -TrueFalse I should cough and take deep breaths after my surgery. - Select -TrueFalse I will be asked to rate my pain using a 0 to 10 scale. 10 would inicate the highest level of pain. - Select -TrueFalse I will be on bed rest until the next morning after my surgery. - Select -TrueFalse Please include any additional questions or comments you have in the field below. Was our online video helpful? Did the video help to adequately prepare you for your procedure? - Select -YesNo Did your support person or coach view this video with you? - Select -YesNo If you feel the video was not helpful, what could we have done better?
