Patient Name *
Email
Joint Registry Reference (if known)
Operating Surgeon
Question 1 - How would you describe the pain you usually had from your operated on hip? *
- Select - None Very mild Mild Moderate Severe
Question 2 - For how long have you been able to walk before the pain from your operated on hip becomes severe? (with or without a stick) *
- Select - No pain/more than 30 minutes 16 to 30 minutes 5 to 15 minutes Around the house only Unable to walk because of severe pain
Question 3 - Have you had any trouble getting in and out of a car or using public transport because of your operated on hip? *
- Select - No trouble at all Very little trouble Moderate trouble Extreme difficulty Impossible to do
Question 4 - Have you been able to put on a pair of socks, stockings or tights? *
- Select - Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible
Question 5 - Could you do the household shopping on your own? *
- Select - Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible
Question 6 - Have you had any trouble with washing and drying yourself (all over) because of your operated on hip? *
- Select - No trouble at all Very little trouble Moderate trouble Extreme difficulty Impossible to do
Question 7 - How much has pain from your operated on hip interfered with your usual work (including housework)? *
- Select - Not at all A little bit Moderately Greatly Totally
Question 8 - After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your operated on hip? *
- Select - Not at all painful Slightly painful Moderately painful Very painful Unbearable
Question 9 - Have you had any sudden, severe pain - 'shooting', 'stabbing' or 'spasms' - from the affected operated on hip? *
- Select - No days Only 1 or 2 days Some days Most days Every day
Question 10 - Have you been limping when walking, because of your operated on hip? *
- Select - Rarely/never Sometimes, or just at first Often, not just at first Most of the time All of the time
Question 11 - Have you been able to climb a flight of stairs? *
- Select - Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible
Question 12 - Have you been troubled by pain from your operated on hip in bed at night? *
- Select - No nights Only 1 or 2 nights Some nights Most nights Every night
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