Hip Questionnaire: 6 Week or 1 Year Surgical Follow-Up with Dr. Fowble

HIP QUESTIONNAIRE

6 Week and 1 Year Surgical Follow-Up with Coleman D. Fowble, MD
Name

First NameLast Name
How long ago did Dr. Fowble perform hip surgery on you?

Other
Section I: Follow-up Information
1. This questionnaire is for the evaluation of my _____ hip.
2. I have had problems with my _____ hip(s).
3. Dr. Fowble has operated on my _____ hip(s).
4. Another surgeon has operated on my _____ hip(s).
5. Dr. Fowble performed the following operation(s) on my hip(s).
6. Select the surgical technique used in your hip surgery.
7. Select the facility where your surgery was performed.
Section II: Complications
1. Select any complications you had post-surgery.

Other
2. If you had complications that required further surgery, please explain.
Section III – Clinical Function Score
1. Which category most closely represents your pain level?
2. Please indicate the location of your pain. Select all that apply.

Other
3. Please enter your USUAL hip-related pain level based on the scale above
4. Please enter your HIGHEST hip-related pain level based on the scale above
5. Indicate the severity of your limp, if any.
6. Indicate the level of support you require, if any.
7. Indicate how you take the stairs.
8. I can put socks and shoes on
9. Under what circumstances can you sit comfortably?
10. Are you able to get in and out of a vehicle without help?
11. If you have any unrelated orthopaedic issues that could affect your hip function score (i.e., bad back, arthritis in other hip, non-hip pain, etc), please explain.
12. How is your hip joint now compared to before surgery?
Section IV – Activity Score
1. Enter the number that corresponds to your current level of activity from the options below.
1: Wholly inactive; dependent on others and cannot leave residence

2: Mostly inactive or restricted to minimum activities of daily living

3: Sometimes participates in mild activities like walking, limited housework or shopping

4: Regularly participates in mild activities

5: Sometimes participates in moderate activities like swimming, unlimited housework or shopping

6: Regularly participates in moderate activities

7: Regularly participates in active events like bicycling

8: Regularly participates in very active events like bowling or golf

9: Sometimes participates in impact sports/activities like jogging, skiing, ballet, heavy labor or backpacking

10: Regularly participates in impact sports or activities.
2. Please list any activities that you participate in regularly.
3. Please list any vigorous activities that you occasionally participate in.
4.Indicate your activity level now as compared to before surgery.
Section V – Forgotten Joint Score
Indicate your awareness of your artificial joint in the situations below using this scale:

1: Never 2: Almost never 3: Rarely 4: Sometimes 5: Mostly 6: All the time
a. In bed/at night?
b. When sitting >1 hour?
c. When walking >15 minutes?
d. When taking a bath/shower?
e. When traveling in a car?
f. When climbing the stairs?
g. When walking on uneven ground?
h. When going from a low-seated position to standing?
i. When standing for long periods of time?
j. When doing housework/gardening?
k. When taking a walk/hike?
l. When doing your favorite sport/activity?
Section VI – Conclusion
1. If you are not happy with your decision to have this surgery, please explain why.
2. Do you have any additional comments you would like to share?
Should be Empty:

HIP QUESTIONNAIRE

Section I: Follow-up Information

Section II: Complications

Section III – Clinical Function Score

Section IV – Activity Score

Section V – Forgotten Joint Score

Section VI – Conclusion