Dr. Evanich Joint Questionnaire

This form only needs to be filled out if you or the patient is over 50 years of age.

Please note that Medicare and many private insurance companies are now requiring more extensive documentation of the patient's symptoms, condition, and treatment prior to the consideration of total joint replacement. They require specific and extensive non-operative treatment trials prior to approving surgery for total joint replacement. The following symptoms and conditions must be documented for consideration of total joint replacement:

Pain at the joint involved
Pain increased with activity
Pain increased with weight bearing
Pain that interferes with activities of daily living
Pain with passive range of motion
Limited range of joint motion
Joint grinding or noise (if knee)
Joint swelling (if knee)
Limping gait (if hip)
X-ray findings consistent with degenerative joint disease

Specifically, the pre-surgery treatment trials include:

Continued pain symptoms after trial of medication greater than 4 weeks
Trial of physical therapy (unless patient unable to tolerate) greater than 12 weeks
Trial of external joint support (cane, walker, brace) greater than 12 weeks

The Physicians of Orthopedic Associates will strive to relieve your pain and improve your function with the least invasive treatment required. Often, arthritic pain can be controlled or mitigated with a variety of non-operative treatments. Unfortunately, many non-operative treatments for arthritis often have diminishing returns and eventually cease to be effective. At that time, total joint replacement can become the treatment of choice, offering a proven durable solution in resolving arthritic pain and improving function.

Please be thoughtful and detailed in your completion of these forms. They will aid in determining the best treatment of your knee or hip problem. Thank you for your assistance.

Name *

First Name Last Name

Date of Birth *

Date

Date of Appointment *

Date

Time of Appointment *

: Hour Minutes AM/PM Option

Check the boxes next to the choices that best describe your symptoms and treatment to date. All questions must be answered.

Please check all that apply. More than one choice per question is allowed. If uncertain of exact time frames, please estimate to the best of your ability.

Where is your pain located? *

Hip Knee Both Low back with radiation down leg

Which sides are involved? *

Left Right Both

Is one side worse than the other? *

Left Right Equal

How long have you had symptoms of pain? *

Less than 3 months 3 - 12 months 1 -2 years > 2 years

What is your level of pain overall? 1 = minimal, 10 = severe

What is your level of pain with activity? 1 = minimal, 10 = severe

What is your level of pain at rest? 1 = minimal, 10 = severe

Has your pain worsened recently?

Do you have pain at rest?

Do you have pain at night?

Do you notice diminished motion and stiffness of your joints?

Do you have joint swelling?

Do you notice noise (clicking, creaking) when you move your joint(s)?

Do you experience weakness in the involved extremity?

Do you limp due to pain or weakness?

Have you fallen or stumbled recently due to pain or weakness?

Do you feel that your leg gives way causing you to be unstable in your walking ability/gait?

Do you require assistance to get up from a chair?

Do you require assistance to ambulate (cane, walker, companion)?

Is your overall function declining due to your joint pain?

How far can you walk before experiencing any pain? *

Less than 10 feet 11 - 30 feet 31 - 100 feet more than 100 feet

What worsens your pain? *

Motion of the involved joint Going from a sitting to standing position Weight bearing (standing or walking) Everyday activities (getting dressed, using the bathroom, climbing stairs) All of the above

What significantly decreases your pain? *

Does anything completely relieve your pain?

What completely removes your pain? *

For how long does complete relief last? *

Can you tolerate physical therapy exercises? *

Yes, I am currently in physical therapy No, I have tried and could not tolerate physical therapy due to pain No, I am too limited by pain No, I am too weak No, I am unstable in my ability to walk

Can you tolerate/use anti-inflammatories (e.g. ibuprofen, Naprosyn, Celebrex, Mobic)?

Why not? *

Allergic reaction Renal disease Interference with blood pressure medication Anticoagulant (blood thinner - Coumadin, Plavix, Xarleto) GI condition (peptic ulcer disease or gastroesophageal reflux disease)

Please answer the following questions about your current treatment.

Have you been taking anti-inflammatory medication (e.g. ibuprofen, Naprosyn, Celebrex, Mobic) for 4 weeks or longer?

Name of anti-inflammatory medication *

How long have you taken anti-inflammatory medication? *

What pain relief does anti-inflammatory medication provide? *

Does this pain relief last?

Please list any complications or adverse reactions to anti-inflammatory medication

Have you been taking Tylenol for 4 weeks or longer?

How long have you taken Tylenol? *

What pain relief does Tylenol provide? *

Does this pain relief last?

Please list any complications or adverse reactions to Tylenol

Have you been taking a narcotic pain reliever for 4 weeks or longer?

Name of narcotic pain reliever *

How long have you taken narcotic pain relievers? *

What pain relief do narcotic pain relievers provide? *

Does this pain relief last?

Please list any complications or adverse reactions to narcotic pain relievers

Have you been in physical therapy for 12 weeks or longer?

How long have you been in physical therapy? *

What pain relief does physical therapy provide? *

Does this pain relief last?

Please list any complications to physical therapy

Have you been performing home exercises for 12 weeks or longer?

How long have you been performing home exercises? *

What pain relief do home exercises provide? *

Does this pain relief last?

Please list any complications to home exercises

Have you been using a cane, crutches, walker, or brace for 12 weeks or longer?

Which joint supports have you been using? *

What pain relief do joint supports provide? *

How long have you been using joint supports? *

Does this pain relief last?

Please list any complications to these external joint supports

Have you used Corticosteroid joint injections?

Number of injections *

Last received *

Date

What pain relief do Corticosteroid joint injections provide? *

Does this pain relief last?

Please list any complications to Corticosteroid joint injections

Have you used Hyaluronic acid (gel) joint injections?

Number of series *

Last received *

Date

What pain relief do Hyaluronic acid (gel) joint injections provide? *

Does this pain relief last?

Please list any complications to Hyaluronic acid (gel) joint injections