FOLLOW UP CONSENT FORM

1. How long has it been since your last visit?

2.Since your last visit, are you :

Better
unchanged
worse

3.Visual Analog Score VAS :

0
1
2
3
4
5
6
7
8
9
10

4.Since your last visit, have you:

felt any ( swelling, numbness, tingling weakness)

Developed any allergies

Started to lose weight ?

Improve long walks?

Imporove knee bending?

Stopping the use of Walking canes ( if pt uses) ?

Reduce using of pain killer ?

5. Compliance

Are you committed to

Medical Treatment?

Physiotherapy?

6. Will you recommend this therapy?

7. Advantages? ( Open Questions)

8. Disadvantages? ( Open Questions )

Patient Name
Signature