Age
Weight:
Height:
Sex
Current Occupation:
Pre-op PHYSICAL FUNCTIONING - SCORE
Pre-op ROLE PHYSICAL - SCORE
Pre-op ROLE EMOTIONAL - SCORE
Pre-op BODILY PAIN - SCORE
Pre-op VITALITY - SCORE
Pre-op MENTAL HEALTH - SCORE
Pre-op SOCIAL FUNCTIONING - SCORE
Pre-op GENERAL HEALTH - SCORE
Year 1 PHYSICAL FUNCTIONING - SCORE
Year 1 ROLE PHYSICAL - SCORE
Year 1 ROLE EMOTIONAL - SCORE
Year 1 BODILY PAIN - SCORE
Year 1 VITALITY - SCORE
Year 1 MENTAL HEALTH - SCORE
Year 1 SOCIAL FUNCTIONING - SCORE
Year 1 GENERAL HEALTH - SCORE
Year 5 PHYSICAL FUNCTIONING - SCORE
Year 5 ROLE PHYSICAL - SCORE
Year 5 ROLE EMOTIONAL - SCORE
Year 5 BODILY PAIN - SCORE
Year 5 VITALITY - SCORE
Year 5 MENTAL HEALTH - SCORE
Year 5 SOCIAL FUNCTIONING - SCORE
Year 5 GENERAL HEALTH - SCORE
How satisfied are you with the results of your treatment?
Mental health