Hip Pain Questionnaire

Hip Pain Questionnaire

Personal Details
Name*
Date of Birth

MonthDayYear
Telephone Number

Area CodePhone Number
Mobile Number*
Please enter a valid phone number.
Email*
example@example.com
Occupation*
Next of Kin*
Name
Contact Number*
Please enter a valid phone number.
Referring doctor:*
Name
Contact Number*
Please enter a valid phone number.
Marital status:

SinglePartneredMarriedSeparatedDivorcedWidowed
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Usual GP:*
Name
Contact Number*
Please enter a valid phone number.
Medicare
Position
Expiry Date
Private Health
Veterans Affairs
Card Colour
WORKERS COMPENSATION / THIRD PARTY DETAILS
Are you claiming workers compensation? *

YesNo
Claim Number
Are you claiming workers compensation? *

YesNo
Policy Number
Employers Name
Employers Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Name
Contact Phone
Please enter a valid phone number.
Insurance Company
Date of Injury

MonthDayYear
Date
Questionnaire
Hip pain intensity
Worst Number*   /10
Best Number*   /10
On average Number*   /10
How would you describe your hip pain?*

SharpAcheBurningThrobbingOther
How frequent is your hip pain?*

SometimesMost of the timeConstant
Does your hip do any of the following?*

SwellsGives wayClicksLocks upGrindsFeels weak/unstable

Please tick the characteristic of your pain and draw or shade the pain area in the cartoon below:

------
□□□□
○○○○
∆∆∆∆
xxxx

Numbness
Pins and needles
Burning pain
Stabbing pain
Aching pain

Is your pain as a result of an injury?*

YesNo
(If Work cover or Motor accident claim please fill up the accompanying injury form) Otherwise Please describe the injury here:
What happened? Please describe the-duration, number of episodes, treatments and their effectiveness
What makes the pain worse? *
What relieves the pain? *
Do you feel stiff in the morning or after rest?*

YesNo
If yes, how long does the stiffness last?
Is the pain worse at night?*

YesNo
How long can you walk for?
Do you use a stick or walker?*

YesNo
Are you able to run?*

YesNo
Are you able to drive?*

YesNo
What work restrictions do you have? *
What recreational restrictions do you have? *
Is your problem getting:

BetterWorseStaying same
Are you able to look after yourself?*

YesNo
Do you have problems in any other joint?*

YesNo
If Yes, has it been diagnosed Rheumatoid , Osteoarthritis or some other named disease? Which other Joints are involved?
Have you lost appetite recently? *

YesNo
Have you lost appetite recently? *

YesNo
Have lost weight recently? *

YesNo
How much? Is it intentional or unexplained?
Are you having fevers, hot sweats or chills?*

YesNo
Have you been diagnosed or treated for any cancer? *

YesNo
If yes, please summarise or tell me during the consultation
What pain medications do you take? How long have you been taking these? What treatments have you tried so far? *
Do you think or have you been told you need surgery?*

YesNo
Have you had any hip surgery before?*

YesNo
Please describe if you know what was the surgery?*
Is there any legal case pending?*

YesNo
Do you smoke?*

YesNo
How long you have been smoking and how many you smoke per day ?
Do you drink alcohol?*

YesNo
If yes, how many standard drinks per week?
What’s the reason for making this appointment?*

GP advise the specialist opinionYou wanted to see a specialist and learn more about the cause and management of the pain.You have been advised surgery but you would like to discuss the other optionsYou have tried everything else and would like to discuss and consider whether surgery is indicated or not
Is there anything special you would like to discuss or ask today? *
Signature*

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Hip Pain Questionnaire

WORKERS COMPENSATION / THIRD PARTY DETAILS

Questionnaire