Date of birth
National Insurance number
Name and address of employer.
If not employed state source of income
GP’s name and surgery address
Previous medical history
Do you have any previous medical history which might be relevant. For example, have you had an accident previously in which you Injured your hip?
Do you suffer from any condition such as Diabetes, hypertension, high cholesterol?
Do you take any prescription medication. If so what do you take?
Referral to hospital and initial surgery
Date of referral to hospital for orthopaedic review
Date of surgery
Name of consultant doing surgery
Name and address of hospital
What information, if any, were you given regarding the use of a metal on metal hip over the conventional hip prosthesis
What make of metal on metal hip have you had fitted?
Subsequent problems with your hip
What was the date when you became aware that you had a problem with your hip?
Please describe the investigations and treatment you had to try to establish the cause of these problems.
Subsequent surgery and/or investigations for treatment
Have you had your metal on metal hip prosthesis removed?
If so, please answer the following:
Date of surgery
Name of consultant handling surgery
Name of Hospital
Was the hip prosthesis sent anywhere for assessment? If so, do you know where?
How has your recovery been since the revision of your hip?
Have you made a complaint to your original hospital about the need to have your hip implant revised?
Has your original Hospital contacted you regarding your metal on metal hip joint? If so, what have they advised you to do and have you followed their advice?
What is the current condition with your hip?
Have you had a blood test to test for the presence of metal in your blood? If so, what is the result of this?
Is your treating hospital intending on giving you any follow up in this respect?
Have you had any time off work as a result of having a metal on metal hip joint. For example, if you have had to have it removed did you lose pay?
Have you had to have help from friends or family members as as a result of having a metal on metal hip? If so, what form has this help taken?
Are there any other financial expenses you have had to face as a result of having a metal on metal hip?
Funding your claim
Do you have legal expenses insurance? (This has to be current at the time you had your original hip operation).
Is your preference to have a “no win no fee” arrangement with us?
Previous advice and information
Have you sought legal advice from a solicitor about your hip? If so, what was the result of that consultation?
Have you contacted the manufacturer of your hip joint or have you registered with the De Puy hip recall claims service. If so, what has been the outcome.
Please tell us any other information you think is relevant.
Thank you for completing the questionnaire. We appreciate that it is rather long. We are acting for a number of clients with metal on metal hip prosthesis and we are trying to gather as much information together at an early stage so we can put a strong case to the manufacturer. Therefore, the more information you can give us in this questionnaire the better the case we can put forward for you.