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Patient Information

Name: _________________
Surgery Date: //___
Type of Surgery: □ Hip □ Knee □ Shoulder
Surgeon: _________________

Daily Pain Level Tracking

Rate your pain level from 0 (no pain) to 10 (worst pain)

Week of: //___

Day	Pain Level (0-10)	Medications Taken	Notes
Mon
Tue
Wed
Thu
Fri
Sat
Sun

Physical Therapy Progress

Range of Motion Measurements

Pre-surgery: _____ degrees
Week 1: _____ degrees
Week 2: _____ degrees
Week 4: _____ degrees
Week 6: _____ degrees

Daily Activities Checklist

□ Completed prescribed exercises
□ Used ice/heat as directed
□ Used assistive devices properly
□ Followed weight-bearing restrictions
□ Maintained wound care protocol

Red Flags (Check and Report)

□ Fever over 101.5°F
□ Increased redness or warmth
□ Unusual swelling
□ Drainage from incision
□ Severe pain unrelieved by medication

Follow-up Appointments

First Post-Op: //___
PT Initial: //___
Wound Check: //___
6-Week Follow-up: //___

Joint Replacement Surgery Progress Tracker

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