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Victoria and Five Elms Medical Centre NHS GP surgeries in Essex and Dagenham

Oxford hip score

Oxford hip score

Required fields are labelled

Who are you completing this form for? Required

For example, on behalf of a child or dependent

Yourself

Someone else

What is your name? Required

First name

Last name

What is your date of birth? Required

For example, 31 3 1980

Day

Month

Year

What is your sex? Required

As recorded on your medical record

Male

Female

Other

What is your postcode? Required

The one used to register with your GP

What is your phone number? Required

What is your email address? Required

Anyone else with access to your email account may see responses sent to you

Which surgery are you registered at? Required

Victoria Medical Centre

Five Elms Medical Practice

During the past 4 weeks

How would you describe the pain you usually have in your hip? Required

None

Very mild

Mild

Moderate

Severe

Have you been troubled by pain from your hip in bed at night? Required

No nights

Only 1 or 2 nights

Some nights

Most nights

Every night

Have you had any sudden, severe pain (shooting, stabbing, or spasms) from your affected hip? Required

No days

Only 1 or 2 days

Some days

Most days

Every day

Have you been limping when walking because of your hip? Required

Rarely/Never

Sometimes or just at first

Often, not just at first

Most of the time

All of the time

For how long have you been able to walk before the pain in your hip becomes severe (with or without a walking aid)? Required

No pain for 30 minutes or more

16 to 30 minutes

5 to 15 minutes

Around the house only

Not at all

Have you been able to climb a flight of stairs? Required

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

Have you been able to put on a pair of socks, stockings or tights? Required

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip? Required

Not at all painful

Slightly painful

Moderately painful

Very painful

Unbearable

Have you had any trouble getting in and out of a car or using public transportation because of your hip? Required

No trouble at all

Very little trouble

Moderate trouble

Extreme difficulty

Impossible to do

Have you had any trouble with washing and drying yourself (all over) because of your hip? Required

No trouble at all

Very little trouble

Moderate trouble

Extreme difficulty

Impossible to do

Could you do the household shopping on your own? Required

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

How much has pain from your hip interfered with your usual work, including housework? Required

Not at all

A little bit

Moderately

Greatly

Totally

Terms and conditions Required

I confirm that this is not an emergency and understand the surgery cannot help while it is closed. If I need help right now, I will use the NHS 111 service. In an emergency, I will call 999 or go to A&E.

If you are human, leave this field blank.

Forms Unavailable

Our forms are currently closed. For medical assistance, please call NHS 111, or contact them online using the button below.

For medical emergencies only, please call 999

Victoria Medical Centre
1 Queens Road
Barking
Essex
IG11 8GD

Get directions

020 8477 8760

Five Elms Medical Practice
Five Elms Road
Dagenham
RM9 5TT

Get directions

0208 517 1175

About the surgery

Register with the surgery

Sick (fit) notes

Feedback and complaints

This service is no longer registered with CQC

View this service's archived profile on the CQC website

Five Elms Medical Practice

CQC overall rating

Requires improvement

14 April 2020

See the report

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