Form H 2

Patient Name

Date of Birth (dd/mm/yyyy)

Hospital ID ( UID, MRN, Number)

Gender ( Male/Female)

Hospital Name, City ( Location)

Operation Date (dd/mm/yyyy)

Anaesthesia Type ( GA/SA/EA/Combined)

Surgeon Incharge

Side ( Left/Right)

Indication for Revision

Procedure Type ( Single Stage/Stage I/ Stage II/ Excision Arthroplasty/Arthrodesis)

Primary Operation Date (dd/mm/yyyy)

Implant Removed ( Brand)

Surgical Approach Used

Implant Used for revision

Bone Graft used ( Yes/No)

Complications (If any)

Surgeon UID

Form H 2 ( Revision Hip)