PatientIQ Patient Portal

Outstanding Tasks0

Complete Tasks Below
Click on the items below to complete.

CMS Joint Replacement Survey - HIP

Form

CMS Joint Replacement Survey - HIP
Form

Outstanding Tasks0

Complete Tasks Below
Click on the items below to complete.

CMS Joint Replacement Survey - HIP

Form

CMS Joint Replacement Survey - HIP
Form

CMS Joint Replacement Survey - HIP

Person completing the survey

Self

Surrogate

Race:

White

Black or African-American

Asian

American Indian/Alaska Native

Native Hawaiian/Other Pacific Islander

Other

dummy

Ethnicity:

Non-Hispanic or Not Latino

Hispanic or Latino

dummy

How comfortable are you filling out medical forms by yourself?

Extremely

Quite a bit

Somewhat

A little bit

Not at all

What amount of pain have you experienced in the last week in your other hip?

None

Mild

Moderate

Severe

Extreme

My BACK PAIN at the moment is

None

Very mild

Moderate

Fairly severe

Very severe

Worst imaginable

CMS Joint Replacement Survey - HIP

CMS Joint Replacement Survey - HIP

CMS Joint Replacement Survey - HIPForm

CMS Joint Replacement Survey - HIP

CMS Joint Replacement Survey - HIP

CMS Joint Replacement Survey - HIPForm

CMS Joint Replacement Survey - HIP
Form

CMS Joint Replacement Survey - HIP
Form