Revision Elbow Replacement Questionnaire

If you have had bilateral surgery, please use one form for the left elbow and one form for the right elbow.

If there are reasons other than the operation which would stop you doing one of the tasks listed; try to answer the question from the joint replacement aspect alone.

Patient Name *

Joint Registry Reference (if known)

Date of Birth

Day

Month

Year

Patient Address

Operating Surgeon

Date of Surgery

Day

Month

Year

Dominant Arm *

Left

Right

Side *

Left

Right

Question 1 - During the past 4 week: Have you had difficulty lifting things in your home, such as putting out the rubbish, because of your elbow problem? *

Question 2 - During the past 4 weeks: Have you had difficulty carrying bags of shopping, because of your elbow problem? *

Question 3 - During the past 4 weeks: Have you had any difficulty washing yourself all over, because of your elbow problem? *

Question 4 - During the past 4 weeks: Have you had any difficulty dressing yourself, because of your elbow problem? *

Question 5 - During the past 4 weeks: Have you felt that your elbow problem is "controlling your life"? *

Question 6 - During the past 4 weeks: How much has your elbow problem "been on your mind"? *

Question 7 - During the past 4 weeks: Have you been troubled by pain from your elbow in bed at night? *

Question 8 - During the past 4 weeks: How often has your elbow pain interfered with your sleep? *

Question 9 - During the past 4 weeks: How much has your elbow problem interfered with your usual work or everyday activities? *

Question 10 - During the past 4 weeks: Has your elbow problem limited your ability to take part in leisure activities that you enjoy doing? *

Question 11 - During the past 4 weeks: How would you describe the worst pain you have from your elbow? *

Question 12 - During the past 4 weeks: How would you describe the pain you usually have from your elbow? *

Progress Report

I wish to receive a progress report on the study.

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