HOOS Hip Survey (Hip Osteoarthritis Outcome Survey)

Today’s Date
 

Last Name

First Name

Date of Birth
 

What Time Period Are You Reporting?

Hip Symptoms and Stiffness during the last week

S1. Do you feel grinding, hear clicking or any other type of noise from your hip?

S2. Difficulties spreading legs wide apart

S3. Difficulties to stride out when walking

S4. How severe is your hip joint stiffness after first wakening in the morning?

S5. How severe is your hip stiffness after sitting, lying or resting later in the day?

Pain

P1. How often is your hip painful?

Pain in the hip during the last week when doing the following activities:

P2. Straightening your hip fully

P3. Bending your hip fully

P4. Walking on flat surface

P5. Going up or down stairs

P6. At night while in bed

P7. Sitting or lying

P8. Standing upright

P9. Walking on a hard surface (asphalt, concrete, etc)

P10. Walking on an uneven surface

Function and Daily Living (Physical Function)

How difficult is each of the following activites during the last week due to your hip?

Al. Descending stairs

A2. Ascending stairs

A3. Rising from sitting

A4. Standing

A5. Bending to floor/pick up an object

A6. Walking on flat surface

A7. Getting in/out of car

A8. Going shopping

A9. Putting on socks/stockings

A10. Rising from bed

A11. Taking off socks/stockings

A12. Lying in bed (turning over, maintaining hip position)

A13. Getting in/out of bath

A14. Sitting

A15. Getting on/off toilet

A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)

A17. Light domestic duties (cooking, dusting, etc)

Function, Sports and Recreational Activities (physical function when active on a higher level) Think about the degree of difficulty when doing the following activities during the last week due to your hip?

SP1. Squatting

SP2. Running

SP3. Twisting/pivoting on your injured hip

SP4. Walking on uneven surface

Quality of Life.

Q1. How often are you aware of your hip problem?

Q2. Have you modified your life style to avoid potentially damaging activities to your hip?

Q3. How much are you troubled with lack of confidence in your hip?

Q4. In general, how much difficulty do you have with your hip?

Thank you for completing this questionnaire!

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