Hoos, Jr. Hip Survey
This survey asks for your view about your hip. This information will help us keep track of how you feel about your hip and how well you are able to do your usual activities. Answer every question by choosing the most appropriate option.
Name
*
First Name
Last Name
Pain: What amount of hip pain have you experienced the last week during the following activities
*
Rows
None
Mild
Moderate
Severe
Extreme
Going up or down stairs
Walking on an uneven surface
Function, Daily Living: The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your hip.
*
Rows
None
Mild
Moderate
Severe
Extreme
Rising from sitting
Bending to floor/pick up an object
Lying in bed (turning over, maintaining hip position)
Sitting
Final Score
Date
*
-
Month
-
Day
Year
Date
Signature
*
Scoring Instructions
Raw Score
Interval Score
0
100.00
1
92.340
2
85.257
3
80.550
4
76.776
5
73.472
6
70.426
7
67.516
8
54.554
9
61.815
10
58.930
11
55.985
12
52.965
13
49.858
14
46.652
15
43.335
16
39.902
17
36.363
18
32.735
19
29.009
20
25.103
21
20.805
22
15.633
23
8.104
24
0
Submit
Should be Empty: