WestmeadKatoombaPenrithMerrylandsBella Vista Book an Appointment Please enable JavaScript in your browser to complete this form.LayoutName *Email *Phone *LayoutClinic Location *Clinic Location...WestmeadSky 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 nightsOnly 1 or 2 nights Some nights Most nightsEvery 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 timeAll 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 minutes5 to 15 minutesAround the house onlyNot at all* 6. Have you been able to climb a flight of stairs? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficultyNo, impossible* 7. Have you been able to put on a pair of socks, stockings or tights? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficultyNo, 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 troubleExtreme 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 troubleExtreme difficultyImpossible to do* 11. Could you do the household shopping on your own? *Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficultyNo, 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 MildMildModerateSevere* 2. Have you had any trouble washing and drying yourself (all over) because of your knee? *No trouble at all Very little troubleModerate troubleExtreme difficultyImpossible 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 troubleModerate troubleExtreme 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 minutes5 - 15 minutesAround the house onlyImpossible 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 painfulModerately painVery painfulUnbearable* 6. Have you been limping when walking, because of your knee? * Rarely / never Sometimes or just at firstOften, not just at firstMost of the timeAll of the time* 7. Could you kneel down and get up again afterwards? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficultyNo, impossible* 8. Are you troubled by pain in your knee at night in bed? *Not at all Only one or two nightsSome nightsMost nightsEvery night* 9. How much has pain from your knee interfered with your usual work? (including housework) *Not at all A little bitModeratelyGreatlyTotally* 10. Have you felt that your knee might suddenly give way or let you down? *Rarely / Never Sometimes or just at firstOften, not at firstMost of the timeAll the time* 11. Could you do household shopping on your own? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficultyNo, impossible* 12. Could you walk down a flight of stairs? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficultyNo, impossibleTHE SHOULDER QUIZ Oxford Shoulder Questionnaire* 1. How would you describe the worst pain you had from your shoulder? *None Very MildMildModerateSevere* 2. Have you had any trouble dressing yourself because of your shoulder? *No trouble at all Very little troubleModerate troubleExtreme difficultyImpossible 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 troubleModerate troubleExtreme difficultyImpossible 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 difficultyNo, impossible* 5. Could you do the household shopping on your own? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficultyNo, impossible* 6. Could you carry a tray containing a plate of food across a room? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficultyNo, impossible* 7. Could you brush/comb your hair with the affected arm? *Yes, easily With little difficultyWith moderate difficultyWith extreme difficultyNo, impossible* 8. How would you describe the pain you usually had from your shoulder? *None Very mildMildModerateSevere* 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 difficultyNo, impossible* 11. How much has pain from your shoulder interfered with your usual work (including housework)? *Not at allA little bitModeratelyGreatlyTotally* 12. Have you been troubled by pain from your shoulder in bed at night? * No nights Only 1 or 2 nightsSome nightsMost nightsEvery nightYour ScoreFile Upload Click or drag a file to this area to upload. Please, upload your file (GP Referral)X-Ray Imaging LinkMessage *Submit2653
