HOOS-12
Hip disability and Osteoarthritis Outcome Score
Name
*
First Name
Last Name
Email
*
example@example.com
Today's Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
If you are completing this form regarding a different date, enter it here (Month, Day, Year)
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please indicate which hip this survey is about:
*
Left
Right
VAS: Overall, how bad is your pain (0=no pain, 100 =maximum imaginable pain)
*
Pain
*
Rows
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?
*
Rows
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.
*
Rows
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
*
Rows
Never
Monthly
Weekly
Daily
Always
9. How often are you aware of your hip problem?
Quality of Life
*
Rows
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
Submit
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