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*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920HiddenHave 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 Day Month Year 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: 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: None 1 2 3 4 or more 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 detailsHave 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 detilsDo you have any other health problems(if yes please give details below) Yes No Health problem detailsAllergies(if yes please give details below) Yes No Allergies detailsName of GP Health Insurance Details:Please select your health insurer:(please tick the appropriate one) VHI Laya Irish Life ESB GMA POMAS None/Self Pay 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 PhonePayment detailsCountry* 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 HiddenAdministrative Email* Δ
