Total Ankle Replacement Questionnaire

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

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)

Patient Address

Date of Birth

Day

Month

Year

Operating Surgeon

Date of Surgery

Day

Month

Year

Side *

Left

Right

Question 1 - During the past 4 weeks this has applied to me: I have pain in my foot/ankle *

Question 2 - During the past 4 weeks this has applied to me: I avoid walking long distances because of pain in my foot/ankle *

Question 3 - During the past 4 weeks this has applied to me: I change the way I walk due to pain in my foot/ankle *

Question 4 - During the past 4 weeks this has applied to me: I walk slowly because of pain in my foot/ankle *

Question 5 - During the past 4 weeks this has applied to me: I have to stop and rest my foot/ankle because of pain *

Question 6 - During the past 4 weeks this has applied to me: I avoid some hard or rough surfaces because of pain in my foot/ankle *

Question 7 - During the past 4 weeks this has applied to me: I avoid standing for a long time because of pain in my foot/ankle *

Question 8 - During the past 4 weeks this has been applied to me: I catch the bus or use the car instead of walking, because of pain in my foot/ankle *

Question 9 - During the past 4 weeks this has applied to me: I feel self-conscious about my foot/ankle *

Question 10 - During the past 4 weeks this has applied to me: I feel self-conscious about the shoes I have to wear *

Question 11 - During the past 4 weeks this has applied to me: The pain in my foot/ankle is more painful in the evening *

Question 12 - During the past 4 weeks this has applied to me: I get shooting pains in my foot/ankle *

Question 13 - During the past 4 weeks this has applied to me: The pain in my foot/ankle prevents me from carrying out my work/everyday activities *

Question 14 - During the past 4 weeks this has applied to me: I am unable to do all my social or recreational activities because of pain in my foot/ankle *

Question 15 - During the past 4 weeks: How would you describe the pain you usually have in your foot/ankle? *

Question 16 - During the past 4 weeks: Have you been troubled by pain from your foot/ankle in bed at night? *

Progress Report

I wish to receive a progress report on the study.

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