Skip to content
Verification of Preoperative Education
Please fill out the questionnaire below. The feedback gained from this survey ensures that Northwest Specialty continues our goal of providing the best patient education possible. We greatly appreciate your participation.
*
1.
Patient's name:
(Required.)
*
2.
Patient's date of birth:
(Required.)
*
3.
Patient's phone number:
(Required.)
*
4.
Patient's email address:
(Required.)
*
5.
Who is your surgeon?
(Required.)
*
6.
What surgery are you scheduled to have?
(Required.)
left Hip
Right Hip
Left Knee
Right Knee
Left Shoulder
Right Shoulder
Spine
Other (please specify)
*
7.
What is the most important thing you need to do before a dressing change to prevent an infection?
(Required.)
Put on gloves
Wash your hands
Use lotion on your hands
Do Nothing
*
8.
After watching the video, I understand that applying _______to my surgical site is an important part of my pain management plan.
(Required.)
Cold
Heat
*
9.
Symptoms of a surgical site infection include:
(Required.)
Yellow or green discharge
Increased redness and warmth
Excessive swelling and pain
Fever
All of the above
*
10.
I understand how to setup my home for safety and fall prevention?
(Required.)
True
False
*
11.
Which medication prevents blood clots?
(Required.)
Tylenol
Opiates
IV fluids
Blood thinner
*
12.
Activity and exercises will help aid in my recovery.
(Required.)
True
False
*
13.
Please rate the quality of the education you have received.
(Required.)
Excellent
Good
Average
Below Average
Poor
Other (please specify)
*
14.
What is your preferred learning style?
(Required.)
Booklets or manuals
In person classes
Web based videos
*
15.
Was the education viewed by support person(s)? Anyone that will be helping the patient before or after surgery.
(Required.)
Yes
No
16.
Do you have any suggestions or comments you would like to share?
