Revision Hip Replacement Questionnaire

If you have had bilateral surgery please use one form for the left hip and one form for the right hip.

If there are reasons other than the operation which would stop you doing one of the tasks listed, try to answer the question from the joint replacement aspect alone.

Patient Name *

Joint Registry Reference (if known)

Date of Birth

Day

Month

Year

Patient Address

Operating Surgeon

Date of Surgery

Day

Month

Year

Side *

Left

Right

Question 1 - How would you describe the pain you usually had from your operated on hip? *

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) *

Question 3 - Have you had any trouble getting in and out of a car or using public transport because of your operated on hip? *

Question 4 - Have you been able to put on a pair of socks, stockings or tights? *

Question 5 - Could you do the household shopping on your own? *

Question 6 - Have you had any trouble with washing and drying yourself (all over) because of your operated on hip? *

Question 7 - How much has pain from your operated on hip interfered with your usual work (including housework)? *

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? *

Question 9 - Have you had any sudden, severe pain - 'shooting', 'stabbing' or 'spasms' - from the affected operated on hip? *

Question 10 - Have you been limping when walking, because of your operated on hip? *

Question 11 - Have you been able to climb a flight of stairs? *

Question 12 - Have you been troubled by pain from your operated on hip in bed at night? *

Progress Report

I wish to receive a progress report on the study.

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