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Name of the patient :

Whether Old Patient (O) / New Patient(N) :

Index number :

Date of Surgery :

Complaints :
     
 
  New Patients   Operated Patients

I have severe pain in my knee(s)

I have fever

I have to use cane while walking

There is dicharge coming from my wound

I cannot climb stairs

My feet are red and swollen

I cannot walk for long distance

I am breathless

I limp while walking

My feet are warm to the touch

There is bowing of my leg(s)

My knee(s)/hip(s) have become painful

My knee has become stiff

Other
Other    
 
 
     
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