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PINNACLE™ ACETABULAR CUP
CLINICAL OUTCOMES STUDY
PATIENT INITIALS
DATE OF EXAM
11 06 01
M D Y
WOMAC OSTEOARTHRITIS INDEX (cont.)
Womac Osteoarthritis Index
Section C-Physical Function
Page 2 of 2
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:
|
(1)
None |
(2)
Mild |
(3)
Moderate |
(4)
Severe |
(5)
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. c | |||||
| 16. Heavy domestic duties. | |||||
| 17. Light domestic duties. |
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
PIN9 11/00
PROTECTED DOCUMENT. DOCUMENT SUBJECT TO PROTECTIVE ORDER.
DEPUY090311652
Source: https://www.industrydocuments.ucsf.edu/docs/xggn0226
PLT-00694-00011