Patient Information

*Please provide your full legal name as it appears on your driver's license, state identification card, or government issued identification card.

HOOS Hip Survey

* Required Information

Symptoms

These questions should be answered thinking of your hip symptoms and difficulties during the last week.
*Do you feel grinding, hear clicking or any other type of noise from your hip?
*Difficulties spreading legs wide apart
*Difficulties to stride out when walking

Stiffness

The following questions concern the amount of joint stiffness you have experienced during the last week in your hip. Stiffness is a sensation of restriction or slowness in the ease with which you move your hip joint.
*How severe is your hip joint stiffness after first wakening in the morning?
*How severe is your hip stiffness after sitting, lying or resting later in the day?

Pain

What amount of hip pain have you experienced the last week during the following activities?
*How often is your hip painful?
*Straightening your hip fully
*Bending your hip fully
*Walking on a flat surface
*Going up or down stairs
*At night while in bed
*Sitting or lying
*Standing upright
*Walking on a hard surface (asphalt, concrete, etc.)
*Walking on an uneven surface

Function, daily living

The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your hip.
*Descending stairs
*Ascending stairs
*Rising from sitting
*Standing
*Bending to the floor/pick up an object
*Walking on a flat surface
*Getting in/out of car
*Going shopping
*Putting on socks/stockings
*Rising from bed
*Taking off socks/stockings
*Lying in bed (turning over, maintaining hip position)
*Getting in/out of bath
*Sitting
*Getting on/off toilet
*Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)
*Light domestic duties (cooking, dusting, etc)

Function, sports and recreational activities

The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your hip.
*Squatting
*Running
*Twisting/pivoting on loaded leg
*Walking on uneven surface

Quality of Life

*How often are you aware of your hip problem?
*Have you modified your life style to avoid activities potentially damaging to your hip?
*How much are you troubled with lack of confidence in your hip?
*In general, how much difficulty do you have with your hip?

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Oklahoma City, OK 73189
Form Number 1788
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