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 HiddenEmail Time Period Post Op / Injection* What surgery / procedure did you have:*(please tick the appropriate box below) Left Hip Replacement Right Hip Replacement Left Knee Replacement Right Knee Replacement Revision Left Hip Replacement Revision Right Hip Replacement Revision Left Knee Replacement Revision Right Knee Replacement Hip Injection / Aspiration Left Hip Hip Injection / Aspiration Right Hip Hip Injection / Aspiration Both Hips Knee Injection / Aspiration Left Knee Knee Injection / Aspiration Right Knee Knee Injection / Aspiration Both Knees 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)None12345678910Does pain disturb your sleep:* Yes No How 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 currently take every day:*none1234 or moreWhat painkiller(s) do you take? How effective are your pain killers:*Not at allSlightly effectiveModerately effectiveVery effectiveHave 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:* Day Month Year (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)No Pain12345678910Does the pain disturb your sleep:* Yes No How 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 currently take every day:*none1234 or moreHow effective are your pain killers:*Not at allSlightly effectiveModerately effectiveVery effectiveName of GP* Please select your health insurer:* Vhi Laya Irish Life ESB GMA POMAS Self Pay/None 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 HiddenAdministrative Email* Δ
