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Molli Pre-Arthroplasty (MPAS) Form

The contents of this form belong to the sole proprietorship of Dr. Ryan Garold Molli. Duplication of the contents within this form are prohibited. All new patients of Whole Health Orthopedic Institute are required to submit the MPAS prior to their consultation appointment. Any questions, please contact our team at: mpas@wholehealthjri.com

"*" indicates required fields

Last*
First*
Email Address*
Your email address will automatically input capitalized - it will not affect the form if your email address has lower case letters.

Section 1

Please answer all questions below to the best of your knowledge and with complete honesty.
With regard to my joint pain, I worry all the time about whether the pain will end*
With regard to my joint pain, I feel I can't go on*
With regard to my joint pain, it's terrible and I think it's never going to get any better*
With regard to my joint pain, it's awful and I feel that it overwhelms me*
With regard to my joint pain, I feel I can't stand it anymore*
With regard to my joint pain, I become afraid that the pain will get worse*
With regard to my joint pain, I keep thinking of other painful events*
I anxiously want the joint pain to go away*
I can't seem to keep my joint pain out of my mind*
I keep thinking about how much my joint pain hurts*
I keep thinking about how badly I want the joint pain to stop*
With regard to my joint pain, I feel there is nothing I can do to reduce the intensity of the pain*
With regard to my joint pain, I wonder whether something serious may happen*

Section 2

Please answer all questions below to the best of your knowledge and with complete honesty.
Anxiety*
Depression*
Medication/Chemical Allergies*
Metal Allergies*
Indoor Pets (dogs)*
Indoor Pets (cats)*

Section 3

Please answer all questions below to the best of your knowledge and with complete honesty.
Tobacco Use (all forms of tobacco, such as cigarettes, cigars, smokeless tobacco, Nicorette or any other form of nicotine)*
Illicit Drug Use (This does not include marijuana)*
Marijuana Drug Use*

Section 4

Please answer all questions below to the best of your knowledge and with complete honesty.
Previous Surgical Site*
Previous Bone & Joint Infection*
Previous Joint Replacement*

Section 5

Please answer all questions below to the best of your knowledge and with complete honesty.
Medical History*
Protocols*
Previous Experience*
Employment*
Surgery Assistance*
Deep Venous Thrombosis(DVT)/Previous DVT*
DVT is also known as a lower extremity blood clot.
Blood Thinner*
Do You Have Diabetes?*