Hip Replacement Pre-Op QPROM

Thank you for choosing Kinvara Private Hospital for your hip replacement. Please complete this short questionnaire (known as a Quality Patient-Reported Outcome Measure – QPROM).

The questionnaire should only be completed by patients who are due to have hip replacement and will only take a few minutes.

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Name
Date of birth
1. Is anyone helping you fill in this questionnaire?
2. Are you?
3. Which statement best describes your living arrangements?
4. For how long have you had problems with the hip on which you are about to have surgery?

During the past 4 weeks;

5. How would you describe the pain you usually had from your hip?
6. Have you had any trouble with washing and dressing yourself (all over) because of your hip?
7. Have you had any trouble getting in and out of a car or using public transport because of your hip?
8. Have you been able to put on a pair of socks, stocking or tights?
9. Could you do the household shopping on your own?
10. For how long have you been able to walk before pain from your hip becomes severe?
11. Have you been able to climb a flight of stairs?
12. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip?
13. Have you been limping when walking, because of the hip?
14. Have you had any sudden, severe pain, shooting, stabbing or spasms from the affected hip?
15. How much has the pain from your hip interfered with your usual work (including housework)?
16. Have you been troubled by pain from your hip in bed at night?

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

17. Mobility
18. Self-care
19. Usual activities (e.g. work, study, housework, family)
20. Pain/discomfort
21. Anxiety/ Depression
22. In general, how would you rate your general health?
23. Have you been told by a doctor that you have any of the following? (Check all that apply)
24. Do you consider yourself to have a disability?
Please enable JavaScript in your browser to complete this form.
Name
Date of birth
1. Is anyone helping you fill in this questionnaire?
2. Are you?
3. Which statement best describes your living arrangements?
4. For how long have you had problems with the hip on which you are about to have surgery?

During the past 4 weeks;

5. How would you describe the pain you usually had from your hip?
6. Have you had any trouble with washing and dressing yourself (all over) because of your hip?
7. Have you had any trouble getting in and out of a car or using public transport because of your hip?
8. Have you been able to put on a pair of socks, stocking or tights?
9. Could you do the household shopping on your own?
10. For how long have you been able to walk before pain from your hip becomes severe?
11. Have you been able to climb a flight of stairs?
12. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip?
13. Have you been limping when walking, because of the hip?
14. Have you had any sudden, severe pain, shooting, stabbing or spasms from the affected hip?
15. How much has the pain from your hip interfered with your usual work (including housework)?
16. Have you been troubled by pain from your hip in bed at night?

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

17. Mobility
18. Self-care
19. Usual activities (e.g. work, study, housework, family)
20. Pain/discomfort
21. Anxiety/ Depression
22. In general, how would you rate your general health?
23. Have you been told by a doctor that you have any of the following? (Check all that apply)
24. Do you consider yourself to have a disability?