Outcome Centre
Pre Op

What is a score form?

Fields in red are required.
Name:
Date of Birth:
Hospital Number (if known):
Address:
Telephone:
Email Address
Postcode:

Pain (Left Ankle)

 


Pain (Right Ankle)

 
Walking

  
Walking Aids

  
Limp

  
Stairs/Steps

  
Going up and down hills

  
Standing on tip toes

  
Running

  
Your Scores    
Right Ankle  
Left Ankle  

Is there anything you can't do now that you wish you could?
Are there any comments you wish to make?
If you want to sent this form to us now, click 'Submit your score!'
If you would rather print these details and send them to us, click
'Print this form'

If you decide to print your form please sent it to:

The Oswestry Outcome Centre
Institute of Orthopaedics
Oswestry
Shropshire
SY10 7AG