DePuy
a Johnson & Johnson company

DEPUY CLINICAL
NOV 9 2004
RECEIVED

PINNACLETM ACETABULAR CUP
CLINICAL OUTCOMES STUDY

FUP036M+0
For DePuy Use Only
ID 20
Reviewed By 11-29-04 MG
Entered By L22 12/1/04
Days 1277 Interval 36

WOMAC OSTEOARTHRITIS INDEX (cont.) 10-29-04 Jogges

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Section C-Physical Function

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INSTRUCTIONS:

The following questions concern your physical function . By this we mean your ability to move around and to look after yourself. For each of the following activities, please indicate the degree of difficulty you are currently experiencing due to arthritis in your hips and/or knees. (Please mark your answers with an "X")

QUESTION: WHAT DEGREE OF DIFFICULTY DO YOU HAVE WITH:

	None	Mild	Moderate	Severe	Extreme
1. Descending stairs.
2. Ascending stairs.
3. Rising from sitting.
4. Standing.
5. Bending to floor.
6. Walking on flat.
7. Getting in/out of car.
8. Going shopping.
9. Putting on socks/stockings.
10. Rising from bed.
11. Taking off socks/stockings.
12. Lying in bed.
13. Getting in/out of bath.
14. Sitting.
15. Getting on/off toilet.
16. Heavy domestic duties.
17. Light domestic duties.

INCOMPLETE AND/OR UNSIGNED FORM WILL BE RETURNED TO YOU

NOTE: Investigator - Retain canary copy for your files, send white copy to:
Department of Clinical Research, DePuy a Johnson & Johnson Company, PO Box 988 Warsaw, Indiana 46581-0988

CS9 3/00

PROTECTED DOCUMENT. DOCUMENT SUBJECT TO PROTECTIVE ORDER.

DEPUY090305610

PLT-03250-00045

Source: https://www.industrydocuments.ucsf.edu/docs/jggn0226