“Connecting the right patient, with the right surgeon, and the right pathway.”

HOOS JR. Hip Survey (Hip Osteoarthritis Outcome Survey)

INSTRUCTIONS: This survey asks for your view about your hip. This information will help us keep track of how you feel about your hip and how well you are able to do your usual activities.
Answer every question by selecting the appropriate dropdown, only one dropdown for each question. If you are unsure about how to answer a question, please give the best answer you can.

INSTRUCTIONS: This survey asks for your view about your hip. This information will help us keep track of how you feel about your hip and how well you are able to do your usual activities.
Answer every question by selecting the appropriate dropdown, only one dropdown for each question. If you are unsure about how to answer a question, please give the best answer you can.

Today’s Date
 

Last Name

First Name

Date of Birth
 

What Time Period Are You Reporting?

Pain
What amount of hip pain have you experienced the last week during the following activities?

1. Going up or down stairs:

2. 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.

3. Rising from sitting:

4. Bending to floor/pick up an object:

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

6. Sitting:

Thank you for completing this questionnaire!

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