First Name*Last Name*Have you had an ASR implant?*yesnoLocation 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 DD MM YYYY 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:No Pain12345678910one being very mild and ten being the worst pain you can imagineDoes the pain disturb your sleep:YesNoHow far can you walk comfortably without pain:Less than 100 metresLess than 500 metresLess than a kilometreMore than a kilometreHow many pain killers do you take every day:None1234 or moreWhat painkillers do you take?How effective are your pain killers:Not at allSlightly effectiveModerately effectiveVery effectiveDo you have any problems with your:(if yes please give details below)Blood pressureYesNoBlood pressure problem detailsHeartYesNoHeart problem detailsLungsYesNoLungs problem detailsDo you need to take any of the following medications:(if yes please give details below)Blood thinning drugsYesNoBlood thinnings - detailsHeart medicationYesNoHeart medication - detailsDiabetes medicationYesNoDiabetes medication - detailsHave you been admitted to a Hospital or Nursing Home in the last 6 months:(if yes please give details below)YesNoHospital or Nursing Home detailsHave you ever been treated for MRSA or been in contact with someone who has had MRSA:(if yes please give details below)YesNoMRSA contact detilsDo you have any other health problems(if yes please give details below)YesNoHealth problem detailsAllergies(if yes please give details below)YesNoAllergies detailsName of GPHealth Insurance Details:Please select your health insurer:(please tick the appropriate one)VHILayaIrish LifeESBGMAPOMASNone/Self PayInsurance PlanPolicy NumberHow long have you had health insuranceHave you ever had a break in your health insurance cover(If yes please give details)YesNoHealth 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 patientPhonePayment detailsCountry*IrelandUKX-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-rayI don’t need an X-rayTotal 0,00 € Credit Card Card Details Cardholder Name Administrative Email*
