[p. 170]
Section M2 - ARTIFICIAL JOINT PAGE
CHECK ITEM 3
Enter name and person number from Table MDI.
Person No. ____
These next questions are about your artificial joints.
1a. What other type of artificial joint(s) do you have?
Joint
2[] ____
3[] ____
4[] ____
Ask for each entry in 1a.
b. How many artificial (entry in 1a) do you have?
Number
2[] ____
3[] ____
4[] ____
c. Do you have any other artificial joints?
[] No
CHECK ITEM 4
Enter each joint in a separate column as well as name and person number in CHECK ITEM 3. Treat multiple finger joints as a single joint.
These next questions refer to the (artificial (entry in CHECK ITEM 4)/FIRST finger joint that was implanted.)
2. Was the joint actually replaced with an artificial (entry in CHECK ITEM 4), or was something else implanted such as a pin or a plate?
8 [] Something else - (Mark "FIX" box of Table MDI, then go to next column or next device.)
Ask if finger joint; otherwise, skip to 4a.
3. Is the artificial joint you have NOW made of silicone or some other material?
8 [] Other
9 [] DK
4a. Is the artificial (entry in CHECK ITEM 4) you now have a replacement for a previous artificial (entry in CHECK ITEM 4)?
2 [] No (5)
b. How many times has this artificial (entry in CHECK ITEM 4) been replaced?
c. Why did you have the artificial (entry in CHECK ITEM 4) replaced (the LAST time)?
Mark first three mentioned.
01 [] Defect or malfunction
02 [] Loosening
03 [] Infection
04 [] Pain
88 [] Some other reason - Specify ____
Ask for each entry in 4c except "Normal growth"
d. How long after that joing was implanted was this (entry in 4c) first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
2 [] 30-90 days
3 [] More than 90 days
e. How long did you have the artificial (entry in CHECK ITEM 4) before it was replaced with the one you have now?
98 [] 6-11 months
Years ____
f. In what month and year did you get it?
Year 19____
0000 [] Before 1968
9898 [] 1968 or later
[p.171]
Section M2 - ARTIFICIAL JOINT PAGE - Continued
5a. How long have you had the artificial (entry in CHECK ITEM 4) you have NOW?
98 [] 6-11 months
Years ____
b. In what month and year did you get this one?
Year 19____
0000 [] Before 1968
9898 [] 1968 or later
6. Since you received the artificial (entry in CHECK ITEM 4) you have NOW, would you say your mobility in that joint is improved, about the saem, or worse than it was before this (last) implant?
2 [] Same
3 [] Worse
Please tell me if you have had any of the following problems or complications with or as a result of the artificial (entry in CHECK ITEM 4) you have NOW.
7a. Have you had any blood clots?
2 [] No (7c)
9 [] DK
b. How long had you had the artificial (entry in CHECK ITEM 4) when the blood clots were first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
c. Have you had an infection (as a result of the (entry in CHECK ITEM 4) you have NOW)?
2 [] No (7e)
9 [] DK
d. How long had you had the artificial (entry in CHECK ITEM 4) when the infection was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
e. Has the artificial (entry in CHECK ITEM 4) loosened?
2 [] No (7g)
9 [] DK
f. How long had you had the artificial (entry in CHECK ITEM 4) when the loosening was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
g. Have you had increased pain over time (with the (entry in CHECK ITEM 4) you have NOW)?
2 [] No (7i)
9 [] DK
h. How long had you had the artificial (entry in CHECK ITEM 4) when the increased pain was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
i. Have you had any defects with the artificial (entry in CHECK ITEM 4) you have NOW or has it failed to operate properly?
2 [] No (7k)
9 [] DK
j. How long had you had the artificial (entry in CHECK ITEM 4) when the defect or failure was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
2 [] 30-90 days
3 [] More than 90 days
k. Have you had any other problems or complications with or as a result of the artificial (entry in CHECK ITEM 4) you have NOW?
2 [] No (8)
l. What were they?
Record first three mentioned.
02[] ____
03[] ____
Ask for each entry in 7l
m. How long had you had the artificial (entry in CHECK ITEM 4) when the (entry in 7l) was first noticed? Was it less than 30 days, 30 to 90 days, or more than 90 days?
[option for 3 entries in the original document -01 to 03- not presented here]
Comment: 01 -03
2 [] 30-90 days
3 [] More than 90 days
[p.172]
Section M2 - ARTIFICIAL JOINT PAGE - Continued
8. Why did you need to get an artificial (entry in check item 4) in the first place?
Mark all mentioned
02 [] Rheumatoid arthritis
03 [] Arthritis, unspecified
04 [] Injury
05 [] Pain
88 [] Some other reason - Specify ____
Check item 5
Mark appropriate respondent box and enter relationship to MDI person if proxy.
2 [] Self - Telephone
3 [] Proxy - Personal
Go to next column or next device