The Richard Villar Practice: Pre-operative Patient Questionnaire | Thank you for taking the time to answer this questionnaire. It really is very simple: all you need to do is highlight the answer that you feel is most appropriate to describe your condition before your operation. The information will be put onto a fully secure computer system and will be used for research purposes only. If you have any questions or would like further information, please contact the Richard Villar Practice, either by e-mail at rvillar@uk-consultants.co.uk or by telephone on 020 7483 5270. Please ensure that you answer ALL of the questions.
Thank you very much. |
| 1. How would you describe your hip pain? | |
| A. None at all | |
| B. Occasional pain that does not prevent activities | |
| C. Pain that only affects strenuous activities | |
| D. Tolerable pain that affects normal activities | |
| E. Occasional severe pain with requirement for regular painkillers | |
| F. Severe pain, even in bed | |
| 2. How would you best describe your walking? | |
| A. No limp | |
| B. Slight limp | |
| C. Moderate limp | |
| D. Severe limp/incapable of walking | |
| 3. What support do you need for walking? | |
| A. I do not need support | |
| B. One stick for long walks | |
| C. One stick for most of the time | |
| D. One crutch | |
| E. Two sticks | |
| F. Two crutches | |
| G. Incapable of walking | |
| 4. How far can you walk? | |
| A. Unlimited | |
| B. One mile | |
| C. Half a mile | |
| D. Inside the house only | |
| E. Restricted to bed and armchair | |
| 5. How would you describe your ability to walk stairs? | |
| A. Normally without using a handrail | |
| B. Normally but using a handrail | |
| C. Only just capable of climbing stairs | |
| D. Not capable of climbing stairs | |
| 6. How do you put on your shoes and socks/stockings? | |
| A. Easily | |
| B. With difficulty/easily with the aid of a gadget | |
| C. Incapable of putting them on | |
| 7. How do you feel when you are sitting down? | |
| A. Can sit comfortably for one hour | |
| B. Can sit comfortably for half an hour | |
| C. Cannot sit comfortably at all | |
| 8. Are you able to use public transport? (Or would you be able to even if you normally only use a car?) | |
| A. Yes | |
| B. No | |
| Any other notes: |
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