Experiences of metal on metal hip joint replacement

Part 1 - General patient data

You must answer each question in this section to be able to submit the questionnaire.
Please do not use the Back button in your browser or your data will be lost.
You will be given a chance to tell us extra/missing information at the end.

We would like to ask you a few general questions about yourself. Please tick as appropriate.

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Which country do you live in?

 

1a) Your Gender




1b) Your Age







1c) Which of your hips was replaced with a metal-on-metal joint?

Please provide details (if you do not have the exact dates to hand, please estimate):

date of operation

Type of joint

date of operation

Type of joint

1d) Has your metal-on-metal hip replacement(s) been changed (revised)?






If yes - please give details (if you do not have the exact dates to hand, please estimate):

date of operation

Type of joint

date of operation

Type of joint

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