[p. 173]
Section M3 - FIXATION DEVICE (FIX) PAGE
Check item 6
Enter name and person number from Table MDI.
Person No. ____
These next questions are about implants such as pins, screws, nails, wires, rods or plates.
1a. In what part of the body is your implant located?
2[] ____
3[] ____
4[] ____
5[] ____
b. Do you have any implants anywhere else?
[] No
Check item 7
Enter each body part in a separate column, as well as name and person number in check item 6.
2 [] No (3)
b. How many times have you had surgery to replace or repair the implant in your (entry in check item 7)?
c. Why did you have to have surgery to replace or repair the implant in your (entry in check item 7) (the last time)?
Mark first three mentioned.
01 [] Breakage or defect
02 [] Healing problem
03 [] Infection
04 [] Pain or irritation
05 [] Loosening
88 [] Some other reason - Specify ____
Ask for each entry in 2c, except "Normal growth"
d. How long did you have the implant before the (entry in 2c) 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
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
3a. How long has it been since the [surgery for/last surgery on] the implant in your (entry in check item 7)?
98 [] 6-11 months
Years ____
b. In what month and year did you have the (last) surgery?
Year 19____
0000 [] Before 1968
9898 [] 1968 or later
[p.174]
Section M3 - FIXATION DEVICE (FIX) PAGE - Continued
Since the [surgery for/last surgery on] the implant in your (entry in check item 7) have you had any of the following problems or complications?
4a. Have you had an infection?
2 [] No (4c)
9 [] DK (4c)
b. How long after the (last) surgery was the infection 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 any healing problems (since the (last) surgery)?
2 [] No (4e)
9 [] DK
d. How long after the (last) surgery was the healing problem 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. Other than discomfort generally associated with surgery and healing, have you have any pain (since the (last) surgery)?
2 [] No (4g)
9 [] DK (4g)
f. How long after the (last) surgery was the pain 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. Has the implant loosened (since the (last) surgery)?
2 [] No (4j)
9 [] DK (4j)
h. How long after the surgery was the loosening 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 any other problems occurred with the implant since the (last) surgery, such as a part breaking or wearing out?
2 [] No (4k)
9 [] DK (4k)
j. How long after the surgery was this problem 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 since the (last) surgery?
2 [] No (5)
9 [] DK (5)
l. What were they?
Record first three mentioned.
02[] ____
03[] ____
Ask for each entry in 4l:
m. How long after the (last) surgery was the (entry in 4l) 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. 175]
Section M3 - FIXATION DEVICE (FIX) PAGE - Continued
5a. Why did you need to get the implant in your (entry in CHECK ITEM 7) in the first place? Mark all mentioned.
02 [] Deformity
03 [] Infection
04 [] Cancer
88 [] Other - Specify ____
Mark first box or ask:
b. How long ago did you get the first implant in your (entry in check item 7)?
97 [] Less than 6 months
98 [] 6-11 months
Years ____
c. In what month and year did you get it?
Year 19____
0000 [] Before 1968
9898 [] 1968 or later
Check item 8
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