Joint Health Survey | Broward Health

The following questions ask for your views about your health – how you feel and how well you are able to do your usual activities. All kinds of people across the country are being asked these same questions. Their answers and yours will help to improve health care for everyone. There are no right or wrong answers; please choose the answer that best fits your life right now.

Patient Name

1) How much did pain interfere with your normal work?

Telephone

Date of Surgery

Surgeon's Name

Date of Birth

Gender

Female

Male

Prefer not to say

In general, would you say your health is:

The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

1) Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf?

2) Climbing several flights of stairs?

A) During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

1) Accomplished less than you would like.

2) Were limited in the kind of work or other activities.

B) During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

1) Accomplished less than you would like.

2) Didn’t do work or other activities as carefully as usual.

C) During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

D) These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

1) Have you felt calm and peaceful?

2) Did you have a lot of energy?

3) Have you felt downhearted and blue?

4) How much of the time has your physical health of emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

E) We’d like to ask you some questions about how your health may have changed.

1) Compared to one year ago, how would you rate your physical health in general now?

2) Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) now?

Events

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