Home Evaluation Form - Orthopedic Pre-Operative Screening
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1Home Evaluation Form
Orthopedic Pre-Operative Screening
6 Woodland Road, Suite 202
|
St. Helena, CA 94574
(Please complete before pre-operative appointment.)
First Name: ______________________________________ Last Name: ___________________________________
How would you like to be addressed: ________________ Surgeon’s Name: ______________________________
Date of Surgery: __________________ Type of Surgery:
Total Hip
Total Knee
Partial Knee
Living Situation TODAY
1. Live
Alone
With Family
With Spouse
Other ____________________________________
Is assistance available at home after surgery?
Yes
No
Name: _____________________________ Relationship: _______________ Phone: ___________________
2. Live in a
House
Mobile Home
Apartment
Assisted Living
Other ______________
3. Home is
One level
2-Story
Split level
Apartment/elevator
Apartment/stairs
Steps You Will Use At Home After Surgery
4. Steps in home (please indicate number of steps for each area that applies to your home situation):
Front steps: _______ Railing:
None
Split-level steps: _______ Railing:
None
Single
Single
Bilateral
Bilateral
Garage steps: _______ Railing:
None
Basement: _______ Railing:
None
Single
Single
Bilateral
Bilateral
Back steps: _______ Railing:
None
Upstairs: _______ Railing:
None
Single
Single
Bilateral
Bilateral
5. Equipment currently have and/or using:
Walker, type:_______________
Commode
Elevated toilet seat
Cane
Other:_______________________
None
Getting Around
6.
Walks before surgery:
Without assistive device
With walker
With cane
With crutches
7.
Walks:
Outdoors
Indoors only
0-6 blocks
More than 6 blocks
8.
At home, I am unable to:
Dress self
Bathe self
Cook meals
Clean house/do laundry
9.
At this time, my plans at discharge are:
Return home alone
Home with outpatient therapy
Home with family
To relative’s home
Home with home care
Rehab facility: Name ____________________
I do not know
10. Anticipated needs/requests for assistance or equipment:
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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