Metal on metal hip replacement Questionnaire

Personal Information

Full name


Date of birth

Marital status

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?

Current situation

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?

Financial Losses

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.

Other information

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.