Orthpaedic Surgery in Wales

Patient initials

Date of birth

Time from surgery

Do you consent to sharing your data with the Wales hip and knee team. (Any outcomes or research using your data that is published publically will be anonymised).

No Yes

On which side of your body is the affected knee for which you are receiving treatment? If you select both, please note that you will need to answer each question once for your left side and once for your right side.

Left hip Right hip Both hips

Hip Replacement Questionnaire

During the last four weeks…

Q1. How would you describe the pain you usually have from your hip(s)?

Left Hip

Right Hip

Q2. Have you had any trouble with washing and drying yourself (all over) because of your hip(s)?

Left Hip

Right Hip

Q3. Have you had any trouble getting in and out of a car or using public transport because of your hip(s)?

Left Hip

Right Hip

Q4. Have you been able to put on a pair of socks, stockings or tights?

Left Hip

Right Hip

Q5. Could you do the household shopping on your own?

Left Hip

Right Hip

Q6. For how long have you been able to walk before pain from your hip(s) becomes severe? (with or without a stick)

Left Hip

Right Hip

Q7. Have you been able to climb a flight of stairs?

Left Hip

Right Hip

Q8. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip(s)?

Left Hip

Right Hip

Q9. Have you been limping when walking, because of your hip(s)?

Left Hip

Right Hip

Q10. Have you had any sudden, severe pain - 'shooting', 'stabbing' or 'spasms' - from the affected hip(s)?

Left Hip

Right Hip

Q11. How much has pain from your hip(s) interfered with your usual work (including housework)?

Left Hip

Right Hip

Q12. Have you been troubled by pain from your hip(s) in bed at night?

Left Hip

Right Hip