Hip FormPlease complete this form prior to your appointment. Medical History Name First Name Last Name Date of Birth Past Medical History Please tick all that apply Anaemia Arthritis Asthma Cancer Diabetes Emphysema Epilepsy Gout Heart Disease Hepatitis High Blood Pressure Kidney Disease Rheumatoid Arthritis Sleep Apnoea Stroke Thyroid Disease Ulcers Others Others (Please specify) Past Surgical History Please list all surgeries, doctor's name, hospital and year Medications (include herbal supplements) Please list all currentmedications and supplements, including dosage and frequency Allergies (If any) Alcohol intake (Please select) Never Rarely Moderate Daily Smoking Never Yes I have quit If yes, how many per day If quit, which year? Hip Problem Location Right hip Left hip Both If both hips, which is worse? (Please select) Left Right What are your symptons? If an injury, how did it happen? Pain Description Pain Location Groin Buttock Outer Pain Character Sharp Ache Burning Severity of pain (1-10) Duration of pain Pain aggravated by Pain relieved by Does your pain wake you at night? Yes No Do you have any pain with stairs? Yes No Joint Description Swelling Yes No Stiffness Yes No Giving way Yes No Clicking Yes No Current Restrictions (Please select all that apply) Shower Walking distance Driving a car Dressing Stairs Shoes & Socks Public transport Getting in / out of car Walking aids What treatment have you had for your hip? (Please select all that apply) Physiotherapy Medication Injections Surgery Other Treatment details Thank you! Your form has been submitted. We look forward to seeing you at your appointment.
