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VR-12 Hip

Today’s Date
 

Last Name

First Name

Date of Birth
 

Date of Surgery
 

What Time Period Are You Reporting?

What is your gender?

Q1. In general, would you say your health is:

Activities Questions
The following questions are about activities during a typical day.

Q2a. Does your health now limit you to moderate activities? i.e. moving a table, pushing a vacuum

Q2b. Does your health now limit you when climbing several flights of stairs?

Physical Health during the past 4 weeks

Q3a. Have you been able to accomplish work or regular daily activities?

Q3b. Were you limited in the kind of work or other activities?

Emotional Difficulty during the past 4 weeks

Q4a. Have you accomplished less than you would like with your work or other regular daily activities due to emotional problems (feeling depressed or anxious?)

Q4b. Have you been more careless than usual with work or other activities as a result of emotional problems?

Q5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

The following questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give one answer that comes closest to your feelings.

Q6a. How much of the time during the past 4 weeks have you felt calm and peaceful?

Q6b. How much of the time during the past 4 weeks did you have a lot of energy?

Q6c. How much of the time during the past 4 weeks have you felt downhearted and blue?

Q7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (visiting friends, relatives, etc.)?

Q8. Compared to one year ago, how would you rate your physical health in general now?

Q9. Compared to one year ago, how would you rate your emotions now? (feeling anxious, depressed, irritable)

Thank you for completing this questionnaire!

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