* 1. Name: * 2. Phone number: 3. Email Address: * 4. Date of Birth: (MM/DD/YYYY) * 5. Name of doctor performing your surgery: ---Select One-- Dr. Taylor Cates Dr. Kevin Charron Dr. Anthony Colpini Dr. Said Elshihabi Dr. Richard Gullick Dr. Krishna Gumidyala Dr. Richard Herman Dr. Ki-Hon Lin Dr. Daniel Maxwell Dr. Shomari Ruffin Dr. Greg Slappey Dr. Adam Sunderland * 6. Who will be assisting you at home after surgery? This person is sometimes called your "coach." * 7. What is your "coaches" relationship to you? * 8. Equipment you currently have: Cane Crutches Standard walker Rolling walker Rollator (4 wheels with brakes and seat) Wheel chair 3/1 Commode chair Tub chair Shower bench Oxygen I have no equipment * 9. In feet, approximately how far are you able to walk without sitting down? Less than 5 feet5 to 50 feetApproximately 50 feet50 to 100 feet100 to 200 feetGreater than 200 feet * 10. What should you bring with you on the day of your surgery? ---Select One-- Loose comfortable clothing to wear while at the hospital Your medications in the correct bottles Your orange Academy binder Any braces given to you for use after your surgery Power of Attorney or Living Will All of the above * 11. When preparing your home for return after surgery, you should: ---Select One-- Install rails on stairs Have someone assist with pets Prepare nutritious meals Remove tripping hazards such as electrical cords and throw rugs All of the above * 12. When should you expect to begin walking with assistance after surgery? ---Select One-- 2 days after surgery The day of surgery After I get home * 13. Before getting out of bed while in the hospital, it is essential to: ---Select One-- Push the call button and ask for assistance. It is important I never get up alone in the hospital Use furniture in my room to lean on Ask my family to help me up Yell HELP! over and over again, then get up alone * 14. Any questions, comments, or concerns? SUBMIT SUBMIT