Name of the patient :
Whether Old Patient (O) / New Patient(N) :
Index number :
Date of Surgery :
I have severe pain in my knee(s)
I have fever
I have to use cane while walking
There is dicharge coming from my wound
I cannot climb stairs
My feet are red and swollen
I cannot walk for long distance
I am breathless
I limp while walking
My feet are warm to the touch
There is bowing of my leg(s)
My knee(s)/hip(s) have become painful
My knee has become stiff