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

LEFT HIP QUESTIONNAIRE: NEW PATIENT

This questionnaire aims to grade the severity of your hip problem as accurately as possible. The questions are subjective and your answers are confidential. I ask each patient to answer these questions upon initial evaluation and after surgery. I compare and track data for each of your hips to facilitate the best outcome so I am requesting that you fill out one form for each hip, even if both are identical. Thanks for your help! Dr. Fowble.
Name*

First NameLast Name
LEFT HIP Section I: Introduction

Answer these questions for your LEFT hip even if it is not the hip that caused you to contact Dr. Fowble.
1. I have had problems with my _____ hip(s).
2. I experience the most pain in my _____ hip(s).
3. Please indicate the location of your pain in your LEFT hip. Select all that apply.

No painSide of thighGroinSide of hipButtockLower backFront of thighOther hipRadiating down my legOther
4. How long have you had pain in your LEFT hip? Please specify the time in number of years, months, weeks or days as applicable.
5. If you have had any previous injuries that could have impacted your LEFT hip, please explain.
6. What activities cause your LEFT hip to hurt?

NoneLaying downSittingBending/squattingWalkingStairsExerciseGoing from sitting to standingTwistingOther
7. What activities are difficult due to LEFT hip pain?
8. What activities have you stopped altogether due to LEFT hip pain?
9. Is your LEFT hip pain made worse by certain movements? If so, explain.
10. Has a doctor ever treated you for LEFT hip pain? If so, explain.
11. Has an orthopaedic surgeon other than Dr. Fowble recommended surgery for your LEFT hip? If so, explain.
12a. List all over-the-counter medications you have PREVIOUSLY used to treat your LEFT hip pain:
12b. List all prescription medications you have PREVIOUSLY used to treat your LEFT hip pain:
13a. List all over-the-counter medications you CURRENTLY take to treat your LEFT hip pain:
13b. List all prescription medications you CURRENTLY take to treat your LEFT hip pain:
14. Have you been to physical therapy to treat your LEFT hip pain? If so, approximately how many sessions did you complete:
15. Have you received injections to treat your LEFT hip pain? If so, indicate how long the pain relief lasted.
16. List any surgeries you have had on your LEFT hip.
17. Please list any other treatments you have received for your LEFT hip pain. Indicate if they relieved your pain and how long that pain relief lasted.
18. What prompted you to contact us for an evaluation?
19. Please list any additional information about your LEFT hip pain here.
LEFT HIP Section II – Clinical Function Score
1. Which category most closely represents your pain level for the LEFT hip?

None, or so insignificant that I ignore itRegularly slightMildModerateSevereDisabling
2. Please enter your USUAL LEFT hip-related pain level based on the scale above
3. Please enter your HIGHEST LEFT hip-related pain level based on the scale above
4. Indicate the severity of your limp, if any.

None, or so insignificant that I ignore itRegularly slightMildModerateSevereDisabling
5. 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
6. Please indicate your ability to walk without a break.

Over 1 mile/unlimited.2-3 blocks or roughly 10-15 minutes6 blocks or roughly 30 minutesIndoor walking onlyTo/from bed and chair 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 LEFT hip function score (i.e., bad back, arthritis in other hip, non-hip pain, etc), please explain.
12. How did you hear about us?
LEFT HIP Section III– 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.
Should be Empty:

LEFT HIP QUESTIONNAIRE: NEW PATIENT

LEFT HIP Section I: Introduction

LEFT HIP Section II – Clinical Function Score

LEFT HIP Section III– Activity Score