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1.	Today's date*

2.	Name (First and Last)*

3.	Date of Birth*

4.	What is your e-mail address? This is only collected for the purpose of sending email reminders to you when it is time to re-take the survey.

5.	This survey must be completed prior to surgery and at intervals of 3 months, 6 months, 1 year, 2 years, and 5 years post surgery. Would you like an email reminder when it is time to complete the survey again?
	Yes No

When are you taking this survey?

If you have not had your surgery yet, please choose "Prior to Surgery."
If you have had your surgery, please select the option that indicates about how long ago your surgery took place

	Prior to Surgery
	3 months post-surgery
	6 months post-surgery
	1 year post-surgery
	2 years post-surgery
	3 years post-surgery
	5 years post-surgery

7.	Surgeon name:

8.	What procedure are you having done? If taking this survery post-surgery, which procedure did you have done?

9.	Which hip are you having replaced? If you are taking this survey post-surgery, which hip did you have replaced?

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