Patient Forms

For All Patients

• Information Letter
• Medication History Form
• Patient Information Intake Form
• Self Reporting Pain Tool
• UC Irvine Medical Center Map

Preoperative Patients

• Preoperative Anesthesia Screening Form

Orthopaedic Specialty Form

• Orthopaedic Patient History

Joint Replacement Surgery

All Patients

• Center for Joint Replacement Surgery, New Patient

Form Hip Patients Patient Scheduled for Hip Surgery

• EQ-5D-5L Health-Related Quality of Life
• WOMAC - Index of Osteoarthritis
• UCLA Activity Score
• SF12 Health Survey

Follow up Patient "Hip" Forms

• EQ-5D-5L Health-Related Quality of Life
• WOMAC - Index of Osteoarthritis
• UCLA Activity Score
• SF12 Health Survey

• Information Letter (Spanish)
• Medication History Form (Spanish)
• Orthopaedic Patient History (Spanish)

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