You must have JavaScript enabled to use this form. Dear valued patient, We are glad you have chosen Inova for your joint replacement surgery. After you have viewed the pre-op educational video, please complete the required brief quiz below. Your results will be sent directly to the Joint Replacement Nurse Navigator at the hospital where your surgery is scheduled. First Name Last Name Address Address Address 2 City/Town State/Province - Select -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/Postal Code Email Phone Surgery Date Name of Coach At which Inova hospital are you having your surgery? Inova Alexandria Inova Fair Oaks Inova Loudoun Inova Mount Vernon I should shower with chlorhexidine gluconate (CHG) before my surgery. True False I will need my coach throughout the surgery process while at the hospital on the day of surgery and to assist with recovery in the days following. (A surgery coach can be A FAMILY MEMBER OR FRIEND) True False After surgery, I will be asked to rate my pain using a 0-10 scale. (10 would indicate the highest level of pain.) True False Before being discharged from the hospital, I will have instruction on safe mobility and exercises True False I need to work with my surgeon for a post-op physical therapy plan. True False I should stay active after surgery including ankle pumps and breathing exercises. True False After my surgery, I should use my call bell or in-room phone to call my care team before getting up. True False Does your surgery plan include an overnight stay? No, my surgeon advised I go home the day of surgery Yes, my surgeon had advised to stay overnight at the hospital Did your coach or support person watch the video with you? Yes No Did the video help you to adequately prepare for your surgery? Yes No Other… Enter other… Any additional questions or comments I understand that I will need assistance at home, so I have arranged someone to assist or stay with me for one week after surgery or as needed.
