Post-OP Patient Review Form

Do you have any Covid symptoms

Yes
No

GDPR Consent

I give my consent for my personal data and medical files to be used in this questionnaire.

First Name*

Last Name*

Date of Birth*

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Have you had an ASR implant?*

yes
no

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Email

Time Period Post Op / Injection*

What surgery / procedure did you have:*

(please tick the appropriate box below)

Other

(please give details)

How bad is your pain on a scale of one to ten:*

(one being very mild and ten being very severe)

Does pain disturb your sleep:*

Yes
No

How far can you walk comfortably without pain:*

How many pain killers do you currently take every day:*

What painkiller(s) do you take?

How effective are your pain killers:*

Have you developed any new symptoms since your last visit:*

Yes
No

(if yes please give details of symptoms)

Symptoms details*

Onset of Symptoms - Please provide an exact date:*

(It is very important to provide an exact date of onset of symptoms - your health insurer will determine based on this date as to whether or not you are covered for orthopaedic surgery. Some insurance plans may have excesses / co-payments)

How bad is your pain on a scale of one to ten:*

(one being very mild and ten being very severe)

Does the pain disturb your sleep:*

Yes
No

How far can you walk comfortably without pain:*

How many pain killers do you currently take every day:*

How effective are your pain killers:*

Name of GP*

Please select your health insurer:*

Insurance Plan*

Policy Number:*

Have you had a break in your health insurance cover:

Yes
No

(If yes please give details)

Health insurance break details*

Country*

Ireland
UK

X-RAY*

• All post op and review appointments need an up to date X-ray within 6 months of appointment date.
• 6 Month post op appointments need an up to date X-ray , within 2 months of your appointment date.

I need an X-ray
I don’t need an X-ray

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Administrative Email*

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Email Us