Do you have any Covid symptoms Yes No GDPR Consent I give my consent for my personal data and medical information to be used in this questionnaire First Name* Last Name* Date of Birth* DD slash MM slash YYYY Address*Phone Number* Email address Name of GP* Allergies* Yes No Allergies details* Do you take any of the following blood thinning medications*NoneAspirinWarfarinPlavix (Clopidogrel)Xarelto (Rivaroxaban)Eliquis (Apixaban)OtherOther Have you been admitted to a Hospital or Nursing Home in the last 6 months:* Yes No (if yes please give details below)Hospital Details* Have you ever been treated for MRSA or been in contact with someone who has had MRSA:* Yes No MRSA answer details* Health Insurance Details:Please select your health insurer:* Vhi Laya Irish Life ESB GMA POMAS Self Pay/None (please tick the appropriate)Insurance Plan: Policy Number:* How long have you had health insurance:* Have you ever had a break in your health insurance cover:* Yes No (If yes please give details below)Insurance break details* Next of Kin Details:Name (next of Kin)* Relation* Phone Number (next of kin)* Details of SymptomsLocation of your pain / symptoms:* Left Hip Right Hip Both Hips Left Knee Right Knee Both Knees Other (if other please give details below)Pain details* Date of Onset of Pain / Symptoms* DD slash MM slash YYYY Please provide an accurate date(It is very important to provide an accurate 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 or 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 take every day:*None1234 or moreWhat painkiller(s) 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 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)Heart medication* Yes No Heart Medication details* Diabetes medication* Yes No Diabetes Medication details* Do you have any other health problems:*(if yes please give details below) Yes No Health problems details*HiddenAdministrative-email Δ
