Joint Replacement Quiz - Inova System

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 2

City/Town

State/Province

ZIP/Postal Code

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

Did the video help you to adequately prepare for your surgery?

Yes

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.

CONFIDENTIALITY NOTICE: Communications via email over the internet may not be secure. Although it is unlikely, there is a possibility that information you include in an email can be intercepted and read by other parties besides the person to whom it is addressed. Once received, lnova shall take every precaution to maintain adequate physical, procedural and technical security with respect to our offices and the information storage facilities so as to prevent any loss, misuse, unauthorized access, disclosure or modification of the user's personal information under our control. For additional information about data privacy, please read Inova's web privacy statement.

By submitting this form, you are confirming that you would like to receive health and wellness information from Inova. You can unsubscribe after your submission or anytime if you find it is not meeting your needs.