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PINNACLE™ ACETABULAR CUP
CLINICAL OUTCOMES STUDY
WOMAC OSTEOARTHRITIS INDEX
FU P006m #0
| For DePuy Use Only | |||
| ID | 20 | ||
| Reviewed By | AR 12/19/01 | ||
| Entered By | DRU 1/3/02 | ||
| Days | 211 | Interval | 6 |
| SUBJECT LAST NAME | FIRST NAME | MI | ||||
| SOCIAL SECURITY NUMBER | ||||||
| Left | Right | DATE OF EXAM | SURGEON NAME: | |||
| HIP | 11 | 28 | 01 | Dr. Tigges | ||
| M | D | Y | ||||
| KNEE | ||||||
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 hip and/or knees. For each situation, please enter the amount of pain recently experienced.
QUESTION: HOW MUCH PAIN DO YOU HAVE?
| None | Mild | Moderate | Severe | 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.
| None | Mild | Moderate | Severe | 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? |
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
CS8 3/00
PROTECTED DOCUMENT. DOCUMENT SUBJECT TO PROTECTIVE ORDER.
DEPUY090305590
Source: https://www.industrydocuments.ucsf.edu/docs/jggn0226
PLT-03250-00025