Hip Outcome Score & Modified Harris Hip Score

Hip Outcome Score & Modified Harris Hip Score

Please consider your most symptomatic hip (left OR right, but not both) when answering the following questions:
Date

MonthDayYear
Date
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Hip Pain*

None/Able to ignore itSlight, occasional, no compromise in activityMild, no effect on ordinary activity, pain after activity, use aspirin/ibuprofen/TylenolModerate, tolerable, makes concessions, occasional narcoticMarked, serious limitationsTotally disabled
Limp*

NoneSlightModerateSevereUnable to walk
Support to walk*

NoneCane for long walksCane all the timeCrutch2 canes2 crutchesUnable to walk
Distance walked*

Unlimited6 blocks2-3 blocksIndoors onlyBed and chair
Stairs*

Can go up/down normallyCan go up/down normally with banisterAny methodNot able
Socks/Shoes*

With easeWith difficultyUnable
Sitting*

Any chair, 1 hourHigh chair, 1/2 hourUnable to sit, 1/2 hour, any chair
Public transportation*

Able to enter public transportationUnable to use public transportation (such as bus, or airport transportation)
Harris Hip Score
Hip Outcome Score

Please answer every question with one response that most closely describes your condition within the past week. If the activity in question is limited by something other than your hip, mark not applicable.

ACTIVITIES OF DAILY LIVING

	Not difficult at all	Slight difficulty	Moderate difficulty	Extreme difficulty	Unable to do	Not applicable
Standing for 15 minutes
Getting into and out of an average car
Walking up steep hills
Walking down steep hills.
Going up 1 flight of stairs.
Going down 1 flight of stairs.
Stepping up and down curbs.
Deep squatting.
Getting into and out of a bath tub.
Walking initially.
Walking for approx. 10 minutes.
Walking 15 minutes or greater.
Twisting/pivoting on involved leg.
Rolling over in bed.
Light to moderate work (standing, walking).
Heavy work (push/pulling, climbing, carrying).
Recreational activities.

Sports Subscale

	Not difficult at all	Slight difficulty	Moderate difficulty	Extreme difficulty	Unable to do	Not applicable
Running one mile.
Jumping.
Swinging objects like a golf club.
Landing.
Starting and stopping quickly.
Cutting/lateral movements.
Low impact activities like fast walking.
Ability to perform activity with your normal technique.
Ability to participate in your desired sport as long as you would like.

Please answer the following regarding your current symptoms.

Please consider the worst side when answering the following questions:
Your symptoms are at:*

Right hipLeft hipBoth hips, right worstBoth hips, left worstOther
The location of the symptoms in the hip is:*

FrontSideBack - PosteriorOther
Please draw the location of your symptoms in the figures below*
Date of onset of your symptoms*
Was the beginning of the symptoms associated to trauma or sports injury*

YesNo
Please share any details about the beginning of your symptoms:

Rate your hip pain at rest *

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Rate your hip pain during sports or recreational activities *

	1	2	3	4	5	6	7	8	9	10

1 is Best, 10 is Worst

Pain is worse with:
Pain is better with:
Please indicate associated symptoms:*

Hip catching, popping or lockingNumbness or tinglingLow back painKnee pain - same sidePain with menstrual cyclePain with intercourseBowel/bladder symptomsPain with cough or sneezeNone of the aboveOther
Please list imaging studies performed and date. Remember to bring the images (CDs) you have to your appointment. *
Treatment to date*

No treatment yetAnti-inflammatory medicationRestPhysical therapyInjectionSupport (cane or crutch)InjectionSurgeryOther
In case of INJECTIONS, specify the date, location, image guiding, and relief during the first two hours after injection. Please be as specific as possible
What are your sport or recreational activities?*
What is your goal in treatment?*
Patient Signature*

Clear
Should be Empty:

Hip Outcome Score