Myself Someone Else A Health Care Professional

Hip Relacement Knee Replacement

Hip Knee

Mr. Mrs. Ms.

II III Jr. Sr.

Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Unknown/Unsure 1905 1906 1907 1908 1909 1910 1911 1912 1913 1914 1915 1916 1917 1918 1919 1920 1921 1922 1923 1924 1925 1926 1927 1928 1929 1930 1931 1932 1933 1934 1935 1936 1937 1938 1939 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

I understand and agree that my name, address, and other information that I gave you may be used by DePuy Orthopaedics, Inc., the manufacturer of DePuy Hip and/or DePuy Knee Replacements, and its affiliates. I will receive an information kit and my responses will be used to learn more about patients with osteoarthritis. DePuy may also send me information about other products and programs that may interest me.

Please Select One 1 - Not at all severe 2 3 4 5 - Extremely severe

Please Select One 3 or less times per week 4 or more times per week

Please Select One 1 - Not at all severe 2 3 4 5 - Extremely severe

Please Select One 3 or less times per week 4 or more times per week