HOOS-12 Hip

HOOS-12

Hip disability and Osteoarthritis Outcome Score
Name*

First NameLast Name
Email*
example@example.com
Today's Date*

MonthDayYear
Date
If you are completing this form regarding a different date, enter it here (Month, Day, Year)

MonthDayYear
Date
Please indicate which hip this survey is about:*

LeftRight
VAS: Overall, how bad is your pain (0=no pain, 100 =maximum imaginable pain)*

Pain*

	Never	Monthly	Weekly	Daily	Always
1. How often do you experience hip pain?

Pain - What amount of hip pain have you experienced in the LAST WEEK during the following activities?*

	None	Mild	Moderate	Severe	Extreme
2. Walking on flat surface
3. Going up or down stairs
4. Sitting or lying

Function, daily living - Thinking about the LAST WEEK: The following questions concern your physical function. By this we mean your ability to move around and to look after yourself.*

	None	Mild	Moderate	Severe	Extreme
5. Rising from sitting
6. Standing
7. Getting in/out of a car
8. Walking on uneven surface

Quality of Life*

	Never	Monthly	Weekly	Daily	Always
9. How often are you aware of your hip problem?

Quality of Life*

	Not at all	Mild	Moderate	Severe	Extreme
10. Have much have you modified your life style to avoid activities potentially damaging to your hip?
11. How much are you troubled with a lack of confidence in your hip?
12. In general, how much difficulty do you have with your hip?

Pain Subtotal:
Function and daily living subtotal:
Quality of life subtotal:
Overall HOOS-12 Score
Should be Empty: