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

Location of your current pain / symptoms:

Pain Left Hip
Pain Right Hip
Pain Both Hips
Pain Left Knee
Pain Right Knee
Pain Both Knees

Other (Please give details)

Date of onset of Pain / Symptoms

Please provide an accurate date

(It is very important to provide an accurate date of onset of pain / 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 or co-payments)

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

one being very mild and ten being the worst pain you can imagine

Does the pain disturb your sleep:

Yes
No

How far can you walk comfortably without pain:

Less than 100 metres
Less than 500 metres
Less than a kilometre
More than a kilometre

How many pain killers do you take every day:

What painkillers do you take?

How effective are your pain killers:

Not at all
Slightly effective
Moderately effective
Very effective

Do you have any problems with your:
(if yes please give details below)

Blood pressure

Yes
No

Blood pressure problem details

Heart

Yes
No

Heart problem details

Lungs

Yes
No

Lungs problem details

Do you need to take any of the following medications:
(if yes please give details below)

Blood thinning drugs

Yes
No

Blood thinnings - details

Heart medication

Yes
No

Heart medication - details

Diabetes medication

Yes
No

Diabetes medication - details

Have you been admitted to a Hospital or Nursing Home in the last 6 months:

(if yes please give details below)

Yes
No

Hospital or Nursing Home details

Have you ever been treated for MRSA or been in contact with someone who has had MRSA:

(if yes please give details below)

Yes
No

MRSA contact detils

Do you have any other health problems

(if yes please give details below)

Yes
No

Health problem details

Allergies

(if yes please give details below)

Yes
No

Allergies details

Name of GP

Health Insurance Details:

Please select your health insurer:

(please tick the appropriate one)

Insurance Plan

Policy Number

How long have you had health insurance

Have you ever had a break in your health insurance cover

(If yes please give details)

Yes
No

Health Insurance cover break reason:

If you have an e-mail address please provide your e-mail address below:

Email Address

Next of Kin Details:

Name (Next of Kin)

First Last

Relation to patient

Phone

Payment 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*

Call Us

Email Us

Review Patient Form

one being very mild and ten being the worst pain you can imagine

Health Insurance Details:

Payment details