Patient Hip & Thigh Form

1
Is this a new or long term problem for you?* This field is required.
This is a new problem
This is a long term problem
Enquiry/ advice about a recent consultation
2
Please send your enquiry directly via the link on the text message you were sent instead of using this form.

Kind regards

The MSK team
3
Firstly, have you been treated for this problem before by the NHS?* This field is required.
Yes
No
I'm not sure
4
OK, who have you seen before for this problem? (select all that apply)* This field is required.
My GP
Musculoskeletal/ physio department
Orthopaedic department
5
Which side is your hip or thigh pain?* This field is required.
Left
Both sides
Right
6
Can you narrow down your area of pain?* This field is required.All pictures shown are right sided
7
Have you ever suffered a significant injury to your hip or thigh?* This field is required.
YESNO
8
Type a question
YESNO
9
How long ago was your injury?
Please Select
Please Select
days
weeks
months
years
days, weeks, months, years
Please Select
Please Select
1
2
3
4
5
6
several
many
timescale units
10
Have you felt your current problem as a direct result from your injury?
YESNO
11
How long have you felt your current symptoms for?
Please Select
Please Select
days
weeks
months
years
days, weeks, months, years
Please Select
Please Select
1
2
3
4
5
6
several
many
timescale units
12
Currently, which of the following activities most aggravates your hip or thigh?* This field is required.
Sitting or initially standing after sitting
Prolonged walking or steps/ stairs
Steps/ stairs or squatting movements
I only feel pain with high level activities/ sports
My pain does not depend on my activity or posture
13
Are your current symptoms...* This field is required.
Improving
Staying the same
Worsening
14
Section One Calculation
15
Are you pregnant?
YESNO
16
Do you currently feel unwell or suffer with any other symptoms that concern you?* This field is required.
YESNO
17
Does the time of day or night make any difference to your pain levels?* This field is required.Select NO if it just depends on the type of activity you are doing...
YESNO
18
When using and moving your joint... Do you feel any of the following?Leave BLANK if NO
Inability to weight bear
Giving way or feeling of instability
Inability to lie on your side
Significant stiffness to bending (flexing) the joint
More clicking than normal
19
A musculoskeletal specialist will review your answers along with your GP medical record. Please tell us if you would like:* This field is required.
An online consultation
The specialist should decide with my answers
A telephone consultation
A video consultation
A face to face consultation
20
IMPORTANT: To book your appointment please reply to your earlier text link with this generated code:
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