Write appropriate numbers into appropriate spaces or tick YES/NO as necessary.
Scale: 1=almost no pain;2= mild pain;3=medium pain;4=severe pain; 5=pain beyond relief necessitating use of pain relievers
Scale: 0=no tablet or gel/cream application; 1-40=number of applications of an arthritis cream/gel/tablets
Scale 0=none ;1=; 2=mild; 3=;medium ;4=quite a lot; 5=substantially-pain made it impossible for me to walk
Scale 0=none;1=minimum limitation; 2=mild; 3=medium; 4=substantial;5=virtually no mobility at all
Scale 0=no stiffness; 1=minimum; 2=mild; 3=medium; 4=substantially; 5=stiffness excluding mobility
Please complete 6-12 months after treatment
Please complete 6-12 months after treatment. Scale: 0=absolutely yes; 1=yes- more or less; 2=yes-partially; 3=I am not sure; 4=rather not; 5=not at all
Thank you for your time. Your answers will be collected and used for internal procedures leading to improvement of our services. All your personal information will be handled as confidential and will not be published without your authorization. However, we would like to have your kind consent to use the information that you have provided anonymously for scientific and medicinal purposes. A numerical code will be used instead of your name and results might be eventually published in a medicinal or scientific magazine.