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PINNACLE™ ACETABULAR CUP
CLINICAL OUTCOMES STUDY
FUPO24M#0
| For DePuy Use Only |
| ID 399 |
| Reviewed By 1-21-05 HC |
| Entered By 1/27/05 |
| Days 90.5 Interval 24 |
WOMAC OSTEOARTHRITIS INDEX
Patient Information
Page 1 of 2
SUBJECT LAST NAME FIRST NAME MI
SOCIAL SECURITY NUMBER Left Right DATE OF EXAM SURGEON NAME:
SIDE:
01 06 05 William Barrett
M D Y
Womac Osteoarthritis Index
INSTRUCTIONS:
This survey asks for your views about the amount of pain, stiffness, and disability you are experiencing. All information you furnish will be held in strict confidence. Please answer every question by filling in the appropriate response. If you are unsure about how to answer a question, please give the best answer you can. (Please mark your answers with an "X")
Section A-Pain
INSTRUCTIONS:
The following questions concern the amount of pain you are currently experiencing due to arthritis in your hips and/or knees. For each situation, please enter the amount of pain recently experienced.
QUESTION: HOW MUCH PAIN DO YOU HAVE?
|
(1)
None |
(2)
Mild |
(3)
Moderate |
(4)
Severe |
(5)
Extreme |
|
|---|---|---|---|---|---|
| 1. Walking on a flat surface. | |||||
| 2. Going up or down stairs. | |||||
| 3. At night while in bed. | |||||
| 4. Sitting or lying. | |||||
| 5. Standing upright. |
Section B-Joint Stiffness
INSTRUCTIONS:
The following questions concern the amount of joint stiffness (not pain) you are currently experiencing in your hips and/or knees. Stiffness is a sensation of restriction or slowness in the ease with which you move your joints.
|
(1)
None |
(2)
Mild |
(3)
Moderate |
(4)
Severe |
(5)
Extreme |
|
|---|---|---|---|---|---|
| 1. How severe is your stiffness after first wakening in the morning? | |||||
| 2. How severe is your stiffness after sitting, lying or resting later in the day? |
WOMAC Osteoarthritis Index, Copyright © 1988, Dr. Nicholas Bellamy, Suite 303, Colbourne Building 3, Victoria Hospital, 375 South Street, London, ON N6A 4G5. Journal of Rheumatology, 1988, 15:12, pages 1833-1840
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
PIN8 11/00
PLT-00632-00031
DEPUY090322847
PROTECTED DOCUMENT SUBJECT TO PROTECTIVE ORDER. du/docs/kggn0226