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?

Approximately 6 weeks agoApproximately 1 year agoOther
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.

NoneWound InfectionDislocationFractureLoose ImplantPulmonary embolusPartial Sciatic PalsyOther
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?

None, or so insignificant that I ignore itRegularly slightMildModerateSevereDisabling
2. Please indicate the location of your pain. Select all that apply.

No painSide of thighGroinSide of hipButtockLower backFront of thighOther hipRadiating down my legOther
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.

None, or so insignificant that I ignore itRegularly slightMildModerateSevereDisabling
6. Indicate the level of support you require, if any.

NoneUse of 1 crutch almost alwaysUse of cane or stick almost alwaysUnable to move across the roomUse of 2 crutches or a walkerUse of cane or stick for long walks or high activity only
7. Indicate how you take the stairs.

I cannot take the stairs.Leading with non-painful hip one step at a timeNormally: foot over foot without support of the railingUse of cane or stick for long walks or high activity only
8. I can put socks and shoes on

With easeWith difficultyUnable to put socks/shoes on without help
9. Under what circumstances can you sit comfortably?

Any chair for 1+ hoursA high chair for 30 minutesUnable to sit comfortably
10. Are you able to get in and out of a vehicle without help?

YesNo
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?

Better than my normal, healthy, pre-arthritic/damaged hipFeels just like my normal, healthy, pre-arthritic/damaged hipMuch before than before surgery, with minor aches and painsSomewhat better than before surgeryAbout the sameWorse than 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.

HigherSimilarLower
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