Patient Name *
Email
Joint Registry Reference (if known)
Operating Surgeon
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? *
- Select - No difficulty A little bit of difficulty Moderate difficulty Extreme difficulty Impossible to do
Question 2 - During the past 4 weeks: Have you had difficulty carrying bags of shopping, because of your elbow problem? *
- Select - No difficulty A little bit of difficulty Moderate difficulty Extreme difficulty Impossible to do
Question 3 - During the past 4 weeks: Have you had any difficulty washing yourself all over, because of your elbow problem? *
- Select - No difficulty A little bit of difficulty Moderate difficulty Extreme difficulty Impossible to do
Question 4 - During the past 4 weeks: Have you had any difficulty dressing yourself, because of your elbow problem? *
- Select - No difficulty A little bit of difficulty Moderate difficulty Extreme difficulty Impossible to do
Question 5 - During the past 4 weeks: Have you felt that your elbow problem is "controlling your life"? *
- Select - No, not at all Occasionally Some days Most days Every day
Question 6 - During the past 4 weeks: How much has your elbow problem "been on your mind"? *
- Select - Not at all A little of the time Some of the time Most of the time All of the time
Question 7 - During the past 4 weeks: Have you been troubled by pain from your elbow in bed at night? *
- Select - Not at all 1 or 2 nights Some nights Most nights Every night
Question 8 - During the past 4 weeks: How often has your elbow pain interfered with your sleep? *
- Select - Not at all Occasionally Some of the time Most of the time All of the time
Question 9 - During the past 4 weeks: How much has your elbow problem interfered with your usual work or everyday activities? *
- Select - Not at all A little bit Moderately Greatly Totally
Question 10 - During the past 4 weeks: Has your elbow problem limited your ability to take part in leisure activities that you enjoy doing? *
- Select - No, not at all Occasionally Some of the time Most of the time All of the time
Question 11 - During the past 4 weeks: How would you describe the worst pain you have from your elbow? *
- Select - No pain Mild pain Moderate pain Severe pain Unbearable
Question 12 - During the past 4 weeks: How would you describe the pain you usually have from your elbow? *
- Select - No pain Mild pain Moderate pain Severe pain Unbearable
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