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First Name
Last Name
Email
Phone
Address
Address
Address 2
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State
- None -
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Armed Forces (Canada, Europe, Africa, or Middle East)
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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 -
True
False
Unless instructed otherwise, I should eat or drink after midnight the day before surgery.
- Select -
True
False
I should cough and take deep breaths after my surgery.
- Select -
True
False
I will be asked to rate my pain using a 0 to 10 scale. 10 would inicate the highest level of pain.
- Select -
True
False
I will be on bed rest until the next morning after my surgery.
- Select -
True
False
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 -
Yes
No
Did your support person or coach view this video with you?
- Select -
Yes
No
If you feel the video was not helpful, what could we have done better?
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