Please enable JavaScript in your browser to complete this form.LayoutName *Email *Phone *LayoutClinic Location *Clinic Location...Sky City – Bella VistaNepean Private Specialist CentreKatoombaMerrylandsAppointment Type *Appointment Type..HipKneeShoulder THE HIP QUIZOxford Hip Questionnaire*1. How would you describe the pain you usually have in your hip? *None Very Mild Mild Moderate Severe * 2. Have you been troubled by pain from your hip in bed at night? * No nights Only 1 or 2 nights Some nights Most nights Every night * 3. Have you had any sudden, severe pain (shooting, stabbing, or spasms) from your affected hip? * No days Only 1 or 2 days Some days Most days Every day * 4. Have you been limping when walking because of your hip? *Rarely/never Sometimes or just at first Often, not just at first Most of the time All of the time * 5. For how long have you been able to walk before the pain in your hip becomes severe (with or without a walking aid)? *No pain for 30 minutes or more 16 to 30 minutes 5 to 15 minutes Around the house only Not at all * 6. Have you been able to climb a flight of stairs? *Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible * 7. Have you been able to put on a pair of socks, stockings or tights? *Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible * 8. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip? *Not at all painful Slightly painfulModerately painfulVery painfulUnbearable* 9. Have you had any trouble getting in and out of a car or using public transportation because of your hip? * No trouble at all Very little troubleModerate trouble Extreme difficultyImpossible to do* 10. Have you had any trouble with washing and drying yourself (all over) because of your hip? * No trouble at all Very little troubleModerate trouble Extreme difficultyImpossible to do* 11. Could you do the household shopping on your own? *Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficulty No, impossible* 12. How much has pain from your hip interfered with your usual work, including housework? *Not at allA little bitModeratelyGreatlyTotallyTHE KNEE QUIZOxford Knee Questionnaire* 1. How would you describe the pain you usually have in your knee? *None Very Mild Mild ModerateSevere * 2. Have you had any trouble washing and drying yourself (all over) because of your knee? *No trouble at all Very little trouble Moderate troubleExtreme difficulty Impossible to do * 3. Have you had any trouble getting in and out of the car or using public transport because of your knee? (With or without a stick) *No trouble at all Very little trouble Moderate trouble Extreme difficultyImpossible to do * 4. For how long are you able to walk before the pain in your knee becomes s eve re? (With or without a stick) *No pain > 60 min 16 - 60 minutes 5 - 15 minutes Around the house only Impossible to do * 5. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your knee? *Not at all painful Slightly painful Moderately pain Very painful Unbearable * 6. Have you been limping when walking, because of your knee? * Rarely / never Sometimes or just at first Often, not just at first Most of the time All of the time * 7. Could you kneel down and get up again afterwards? *Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible * 8. Are you troubled by pain in your knee at night in bed? *Not at all Only one or two nights Some nights Most nights Every night * 9. How much has pain from your knee interfered with your usual work? (including housework) *Not at all A little bit Moderately Greatly Totally * 10. Have you felt that your knee might suddenly give away or let you down? *Rarely / Never Sometimes or just at first Often, not at first Most of the time All the time * 11. Could you do household shopping on your own? *Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible * 12. Could you walk down a flight of stairs? *Yes, easily With little difficulty With moderate difficulty With extreme difficulty No, impossible THE SHOULDER QUIZ Oxford Shoulder Questionnaire* 1. How would you describe the worst pain you had from your shoulder? *None Mild ModerateSevere Unbearable* 2. Have you had any trouble dressing yourself because of your shoulder? *No trouble at all Very little trouble Moderate trouble Extreme difficulty Impossible to do * 3. Have you had any trouble getting in and out of a car or using public transport because of your shoulder? *No trouble at all Very little trouble Moderate trouble Extreme difficulty Impossible to do * 4. Have you been able to use a knife and fork at the same time? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficulty No, impossible* 5. Could you do the household shopping on your own? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficulty No, impossible* 6. Could you carry a tray containing a plate of food across a room? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficulty No, impossible* 7. Could you brush/comb your hair with the affected arm? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficulty No, impossible* 8. How would you describe the pain you usually had from your shoulder? *None Very mildMild ModerateSevere* 9. Could you hang your clothes up in a wardrobe, using the affected arm? (whichever you tend to use) *Yes, easilyWith little difficultyWith moderate difficultyWith great difficultyNo, impossible * 10. Have you been able to wash and dry yourself under both arms? *Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficulty No, impossible * 11. How much has pain from your shoulder interfered with your usual work (including housework)? *Not at allA little bit ModeratelyGreatlyTotally* 12. Have you been troubled by pain from your shoulder in bed at night? * No nights Only 1 or 2 nights Some nights Most nights Every night Your ScoreUnderstanding your result on the basis of your Answers Score 0 to 19 Indicates you may have severe knee arthritis. It is highly likely you will need surgical intervention and may be a candidate for a knee replacement. Your GP is most likely to send you for x-rays and refer you to an orthopaedic surgeon for assessment. Score 20 – 29 Indicates you may have moderate to severe arthritis. Your GP is likely to order x-rays and refer you to an orthopaedic surgeon for assessment if the pain is making life very difficult for you. Score 30 – 39 Indicates you may have moderate knee arthritis. Your GP may recommend x-rays if the pain is interfering with your life – and may also suggest non-surgical options (e.g. anti-inflammatory medications). Note that patients who are overweight may benefit from weight loss, as excess weight can put considerable stress on knees. If your knee function and pain worsens over time, your GP may refer you see an orthopaedic specialist. Score 40 – 48 A score in this range indicates you have satisfactory joint function. You are unlikely to require medical intervention. File Upload Click or drag a file to this area to upload. Please, upload your file (GP Referral)X-Ray Imaging LinkMessage *Submit43162