SGCO Logo

    Hip Questionnaire

    Symptoms Assessment

    Have you ever tried any of the following treatments for your hip:

    Functional Assessment

    HOOS. JR Hip Health Survery

    Please read each statement and select which indicates how much the statement applied to you over the past week.  There are no right or wrong answers.  Do not spend too much time on any statement.

    This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to do your usual activities. Answer every question by ticking the appropriate box, only one box for each question. If you are unsure about how to answer a question, please give the best answer you can.

    Pain

    What amount of hip pain have you experienced  in the last week during the following activities?

    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.

    Activity Survey (LEAS)

    Please read through the drop-down list of descriptions and select the   one   description that best fits your regular daily activity.

    Office Use Only

    0 100
    		 7 68
    		 14 47
    		 21 21
    1 92
    		 8 65
    		 15 43

    22 16

    2 85
    		 9 62
    		 16 40
    		 23 8
    3 81
    		 10 59
    		 17 36
    		 24 0
    4 77
    		 11 56
    		 18 33
    5 73
    		 12 53
    		 19 29
    6 70
    		 13 50
    		 20 25

    Save and Complete Later