We would like to ask you a few general questions about yourself. Please tick as appropriate.
This is page 1 of 5
Which country do you live in?
Country... Australia Denmark Ireland New Zealand United Kingdom United States of America Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua & Barbuda Argentina Armenia Aruba Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire Bosnia & Herzegovina Botswana Brazil British Indian Ocean Ter Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Cayman Islands Central African Republic Chad Channel Islands Chile China Christmas Island Cocos Island Colombia Comoros Congo Cook Islands Costa Rica Cote D'Ivoire Croatia Cuba Curacao Cyprus Czech Republic Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Ter Gabon Gambia Georgia Germany Ghana Gibraltar Great Britain Greece Greenland Grenada Guadeloupe Guam Guatemala Guinea Guyana Haiti Hawaii Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Isle of Man Israel Italy Jamaica Japan Jordan Kazakhstan Kenya Kiribati Korea North Korea South Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malaysia Malawi Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Midway Islands Moldova Monaco Mongolia Montserrat Morocco Mozambique Myanmar Nambia Nauru Nepal Netherland Antilles Netherlands (Holland, Europe) Nevis New Caledonia Nicaragua Niger Nigeria Niue Norfolk Island Norway Oman Pakistan Palau Island Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Island Poland Portugal Puerto Rico Qatar Republic of Montenegro Republic of Serbia Reunion Romania Russia Rwanda St Barthelemy St Eustatius St Helena St Kitts-Nevis St Lucia St Maarten St Pierre & Miquelon St Vincent & Grenadines Saipan Samoa Samoa American San Marino Sao Tome & Principe Saudi Arabia Senegal Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa Spain Sri Lanka Sudan Suriname Swaziland Sweden Switzerland Syria Tahiti Taiwan Tajikistan Tanzania Thailand Togo Tokelau Tonga Trinidad & Tobago Tunisia Turkey Turkmenistan Turks & Caicos Is Tuvalu Uganda Ukraine United Arab Emirates Uruguay Uzbekistan Vanuatu Vatican City State Venezuela Vietnam Virgin Islands (Brit) Virgin Islands (USA) Wake Island Wallis & Futana Is Yemen Zaire Zambia Zimbabwe
1a) Your Gender
female male 1b) Your Age
under 35 36-45 46-55 56-65 66-75 over 75
1c) Which of your hips was replaced with a metal-on-metal joint?
Please choose... left right both
Please provide details (if you do not have the exact dates to hand, please estimate):
left
date of operation day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 month Jan Feb Mar April May June July Aug Sept Oct Nov Dec year 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Type of joint
right
1d) Has your metal-on-metal hip replacement(s) been changed (revised)?
Yes No It has been suggested I have an operation date If yes - please give details (if you do not have the exact dates to hand, please estimate):
page 1 of 5