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Follow-up Questionnaires

The Richard Villar Practice: Post-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.

Your Name:
Your E-Mail:
Your Episode Number:
(This will be stated on the letter.)
Follow-up Period:
If you have a different address to that on the letter, please enter it here:



Your Operation:
Operation Date: (This will be stated on the letter.)
Operation Side:

Assessment Questions

Are you currently happy with the result of your operation?
Where would you rate your satisfaction on the visual scale?

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
9. Since your operation, have you had any problems with your hip necessitating readmission?  
A. Yes
B. No
If yes, please explain the problem and give an approximate date:

Any other notes: