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
-
Month
-
Day
Year
Date
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date Picker Icon
Hip Pain
*
None/Able to ignore it
Slight, occasional, no compromise in activity
Mild, no effect on ordinary activity, pain after activity, use aspirin/ibuprofen/Tylenol
Moderate, tolerable, makes concessions, occasional narcotic
Marked, serious limitations
Totally disabled
Limp
*
None
Slight
Moderate
Severe
Unable to walk
Support to walk
*
None
Cane for long walks
Cane all the time
Crutch
2 canes
2 crutches
Unable to walk
Distance walked
*
Unlimited
6 blocks
2-3 blocks
Indoors only
Bed and chair
Stairs
*
Can go up/down normally
Can go up/down normally with banister
Any method
Not able
Socks/Shoes
*
With ease
With difficulty
Unable
Sitting
*
Any chair, 1 hour
High chair, 1/2 hour
Unable to sit, 1/2 hour, any chair
Public transportation
*
Able to enter public transportation
Unable 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
Rows
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
Rows
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 hip
Left hip
Both hips, right worst
Both hips, left worst
Other
The location of the symptoms in the hip is:
*
Front
Side
Back - Posterior
Other
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
*
Yes
No
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
Best
Worst
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
Best
Worst
1 is Best, 10 is Worst
Pain is worse with:
Pain is better with:
Please indicate associated symptoms:
*
Hip catching, popping or locking
Numbness or tingling
Low back pain
Knee pain - same side
Pain with menstrual cycle
Pain with intercourse
Bowel/bladder symptoms
Pain with cough or sneeze
None of the above
Other
Please list imaging studies performed and date. Remember to bring the images (CDs) you have to your appointment.
*
Treatment to date
*
No treatment yet
Anti-inflammatory medication
Rest
Physical therapy
Injection
Support (cane or crutch)
Injection
Surgery
Other
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
*
Submit
Should be Empty: