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	Last name * must provide value
	First name * must provide value
	DOB (Month)	JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
	DOB (Day)	01020304050607080910111213141516171819202122232425262728293031
	DOB (Year)	YYYY
	Sex	Male Female reset
	Today's date	TodayM-D-Y
	Weight (lbs)	Pounds
	Height (in)	48 in = 4 ft49 in = 4 ft 1 in40 in = 4 ft 2 in51 in = 4 ft 3 in52 in = 4 ft 4 in53 in = 4 ft 5 in54 in = 4 ft 6 in55 in = 4 ft 7 in56 in = 4 ft 8 in57 in = 4 ft 9 in58 in = 4 ft 10 in59 in = 4 ft 11 in60 in = 5 ft61 in = 5 ft 1 in62 in = 5 ft 2 in63 in = 5 ft 3 in64 in = 5 ft 4 in65 in = 5 ft 5 in66 in = 5 ft 6 in67 in = 5 ft 7 in68 in = 5 ft 8 in69 in = 5 ft 9 in70 in =5 ft 10 in71 in = 5 ft 11 in72 in = 6 ft73 in = 6 ft 1 in74 in = 6 ft 2 in75 in = 6 ft 3 in76 in = 6 ft 4 in77 in = 6 ft 5 in78 in = 6 ft 6 in79 in = 6 ft 7 in80 in = 6 ft 8 in81 in = 6 ft 9 in82 in = 6 ft 10 in83 in = 6 ft 11 in84 in = 7 ft inches
	Email * must provide value
	MRN
Treatment
	Side of hip problem: * must provide value	Right Left Both: Right side more than Left Both: Left side more than Right Both side equally reset
	Have you ever had surgery on your hip?	Yes No reset
	If YES, what type of surgery or surgeries?	Expand
	What was the date of your surgery or surgeries?	Expand
	Have you ever had surgery on your OTHER hip?	Yes No reset
	If YES, what type of surgery or surgeries?	Expand
	What was the date of your surgery or surgeries?	Expand
Smoking
	Do you currently smoke?	Yes No reset
	Did you ever smoke?	Yes No reset
	For how many years did you smoke?
HEALTH HISTORY The following is a list of common health problems. Please indicate in the first column whether you have this problem. If you do have the problem, indicate in the second column if you have received treatment for it and whether or not it limits your activities in the third column.
	You have the problem You received treatment for it It limits your activities
	Heart Disease
	High Blood Pressure
	Lung Disease
	Diabetes
	Ulcer or Stomach Disease
	Kidney Disease
	Liver Disease
	Anemia or other Blood Disease
	Cancer
	Depression
	Pain and Swelling in Joint
	Low Back Pain
	Osteoporosis
	Fractures
	Blood Clots
	Deep Venous Thrombosis
	Pulmonary Embolism
	Other comorbidity (if applicable)	Please indicate other comorbidity if applicable
	Did you receive treatment for this comorbidity?	Yes No reset
	Does it limit your daily activities?	Yes No reset
Health and Function
	Rate your own health state today. Please do this by sliding the box to whichever point on the scale indicates how good or bad your health state is today. * must provide value	Worst Imaginable Best Imaginable Health State Change the slider above to set a response reset
	How would you rate your hip today as a percentage of normal (on a scale from 0% to 100%) with 100% being normal? * must provide value	0% 100% Change the slider above to set a response reset
	Please select what best describes your activity level over the last 6 months. Select only one response. regularly = once per week or more, sometimes = once per month or less * must provide value	10. I regularly participate in impact sports such as jogging, tennis, skiing, acrobatics, ballet, heavy labor, or backpacking9. I sometimes participate in in impact sports such as jogging, tennis, skiing, acrobatics, ballet, heavy labor, or backpacking8. I regularly participate in very active events such as golf or bowling7. I regularly participate in active events such as bicycling6. I regularly participate in moderate activities such as swimming and unlimited housework or shopping5. I sometimes participate in moderate activities such as swimming and unlimited housework or shopping4. I regularly participate in mild activities such as walking, limited housework and limited shopping3. I sometimes participate in mild activities such as walking, limited housework and limited shopping2. I am mostly inactive: restricted to minimal activities of daily living1. I am wholly inactive: dependent upon others; cannot leave residence
PAIN LEVEL Please mark a number to represent your pain level. 0 = no pain at all, 10 = pain as bad as it can be
	0 1 2 3 4 5 6 7 8 9 10
	What is your pain level right now? * must provide value reset
	What is your typical or average pain? * must provide value reset
	What is your pain level at its best? * must provide value reset
	What is your pain level at its worst? * must provide value reset
Pain Scale and Drawing Please identify any area(s) where you are experiencing pain
	Do you have pain in the groin?	Yes No reset
	Please identify which side you are referring to	Right Left Both sides reset
	Groin pain intensity	Pain at night that wakes you up, or pain all the timePain at rest during the dayPain with daily activities (bathing, getting dressed, going to bathroom, etc.)Pain with moderate activity or specific movements only (getting in/out of a chair or car; going up/down stairs)Pain with extreme activity only (running, excessive walking, etc.)
	Groin pain frequency Daily Weekly Monthly reset
	Do you have pain in the front of your thigh or anterior thigh?	Yes No reset
	Please identify which side you are referring to	Right Left Both sides reset
	Anterior thigh pain intensity	Pain at night that wakes you up, or pain all the timePain at rest during the dayPain with daily activities (bathing, getting dressed, going to bathroom, etc.)Pain with moderate activity or specific movements only (getting in/out of a chair or car; going up/down stairs)Pain with extreme activity only(running, excessive walking, etc.)
	Anterior thigh pain frequency Daily Weekly Monthly reset
	Do you have pain in the knee?	Yes No reset
	Please identify which side you are referring to	Right Left Both sides reset
	Knee pain intensity	Pain at night that wakes you up, or pain all the timePain at rest during the dayPain with daily activities (bathing, getting dressed, going to bathroom, etc.)Pain with moderate activity or specific movements only (getting in/out of a chair or car; going up/down stairs)Pain with extreme activity only(running, excessive walking, etc.)
	Knee pain frequency Daily Weekly Monthly reset
	Do you have pain in the lower back?	Yes No reset
	Lower back pain intensity	Pain at night that wakes you up, or pain all the timePain at rest during the dayPain with daily activities (bathing, getting dressed, going to bathroom, etc.)Pain with moderate activity or specific movements only (getting in/out of a chair or car; going up/down stairs)Pain with extreme activity only(running, excessive walking, etc.)
	Lower back pain frequency Daily Weekly Monthly reset
	Do you have pain in the buttock?	Yes No reset
	Please identify which side you are referring to	Right Left Both sides reset
	Buttock pain intensity	Pain at night that wakes you up, or pain all the timePain at rest during the dayPain with daily activities (bathing, getting dressed, going to bathroom, etc.)Pain with moderate activity or specific movements only (getting in/out of a chair or car; going up/down stairs)Pain with extreme activity only(running, excessive walking, etc.)
	Buttock pain frequency Daily Weekly Monthly reset
	Do you have pain in the back of your thigh or posterior thigh area?	Yes No reset
	Please identify which side you are referring to	Right Left Both sides reset
	Posterior thigh pain intensity	Pain at night that wakes you up, or pain all the timePain at rest during the dayPain with daily activities (bathing, getting dressed, going to bathroom, etc.)Pain with moderate activity or specific movements only (getting in/out of a chair or car; going up/down stairs)Pain with extreme activity only(running, excessive walking, etc.)
	Posterior Thigh Frequency Daily Weekly Monthly reset
	Do you have pain on the side of your hip or trochanteric area?	Yes No reset
	Please identify which side you are referring to	Right Left Both sides reset
	Trochanteric pain intensity	Pain at night that wakes you up, or pain all the timePain at rest during the dayPain with daily activities (bathing, getting dressed, going to bathroom, etc.)Pain with moderate activity or specific movements only (getting in/out of a chair or car; going up/down stairs)Pain with extreme activity only(running, excessive walking, etc.)
	Trochanteric frequency Daily Weekly Monthly reset
	Do you have pain in the side of your thigh or lateral thigh area?	Yes No reset
	Please identify which side you are referring to	Right Left Both sides reset
	Lateral thigh pain intensity	Pain at night that wakes you up, or pain all the timePain at rest during the dayPain with daily activities (bathing, getting dressed, going to bathroom, etc.)Pain with moderate activity or specific movements only (getting in/out of a chair or car; going up/down stairs)Pain with extreme activity only(running, excessive walking, etc.)
	Lateral Thigh Frequency Daily Weekly Monthly reset
	In general, would you say your health is: Excellent Very good Good Fair Poor reset
The following questions are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?
	Yes, limited a lot Yes, limited a little Not limited at all
	Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf reset
	Climbing several flights of stairs reset
During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of your physical health?
	All of the time Most of the time Some of the time A little of the time None of the time
	Accomplished less than would like reset
	Were limited in the kind of work or other activities reset
During the past 4 weeks, how much of the time have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?
	All of the time Most of the time Some of the time A little of the time None of the time
	Accomplished less than you would like reset
	Did work or other activities less carefully than usual reset
	Extremely Quite a bit Moderately A little bit Not at all
	During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)? reset
These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling. How much of the time during the past 4 weeks...
	All of the time Most of the time Some of the time A little of the time None of the time
	Have you felt calm and peaceful? reset
	Did you have a lot of energy? reset
	All the time Most of the time Some of the time A little of the time None of the time
	Have you felt downhearted and depressed? reset
	All the time Most of the time Some of the time A little of the time None of the time
	During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities? reset
SYMPTOMS During the last week
	Always Often Sometimes Rarely Never
	Do you feel grinding; hear clicking or any other type of noise from your hip? reset
	Extreme Severe Moderate Mild None
	Difficulties spreading legs wide apart reset
	Difficulties to stride out when walking reset
STIFFNESS During the last week
	Extreme Severe Moderate Mild None
	How severe is your hip joint stiffness after first wakening in the morning? reset
	How severe is your hip stiffness after sitting, lying or resting later in the day? reset
PAIN During the last week
	Always Daily Weekly Monthly Never
	How often is your hip painful? reset
	Extreme Severe Moderate Mild None
	Straightening your hip fully reset
	Bending your hip fully reset
	Walking on a flat surface reset
	Going up or down stairs reset
	At night while in bed reset
	Sitting or lying reset
	Standing upright reset
	Walking on a hard surface (asphalt, concrete, etc.) reset
	Walking on an uneven surface reset
LIMITATIONS OF DAILY LIVING Difficulty during the last week
	Extreme Severe Moderate Mild None
	Descending stairs reset
	Ascending stairs reset
	Rising from sitting reset
	Standing reset
	Bending to floor/pick up object reset
	Walking on a flat surface reset
	Getting in/out of car reset
	Going shopping reset
	Putting on socks/stockings reset
	Rising from bed reset
	Taking off socks/stockings reset
	Lying in bed (turning over, maintaining hip position) reset
	Getting in/out of bath reset
	Sitting reset
	Getting on/off toilet reset
	Heavy domestic duties (moving heavy boxes, scrubbing floors, etc.) reset
	Light domestic duties (cooking, dusting, etc.) reset
SPORTS & RECREATIONAL ACTIVITIES Difficulty during the last week
	Always Often Sometimes Rarely Never
	Squatting reset
	Extreme Severe Moderate Mild None
	Running reset
	Twisting/pivoting reset
	Walking on uneven surfaces reset
Quality of Life
	Constantly Daily Weekly Monthly Never
	How often are you aware of your hip problem? reset
	Extremely Severely Moderately Mildly Not at all
	Have you modified your life style to avoid potentially damaging activities to your hip? reset
	How much are you troubled with lack of confidence in your hip? reset
	In general, how much difficulty do you have with your hip? reset
Because of your hip, how much difficulty do you have with the following:
	Unable to do Extreme difficulty Moderate difficulty Slight difficulty No difficulty at all N/A
	Standing for 15 minutes reset
	Getting into and out of an average car reset
	Putting on socks and shoes reset
	Walking up steep hills reset
	Walking down steep hills reset
	Going up 1 flight of stairs reset
	Going down 1 flight of stairs reset
	Stepping up and down curbs reset
	Deep squatting reset
	Getting into and out of a bath tub reset
	Sitting for 15 minutes reset
	Walking initially (first few steps) reset
	Walking approximately 10 minutes reset
	Walking 15 minutes or greater reset
	Twisting/pivoting on involved leg reset
	Rolling over in bed reset
	Light to moderate work (standing, walking) reset
	Heavy work (push/pulling, climbing, carrying) reset
	Recreational activities reset
	Running one mile reset
	Jumping reset
	Swinging objects like a golf club reset
	Landing after jumping reset
	Starting and stopping quickly reset
	Cutting/lateral movements reset
	Low impact activities like fast walking reset
	Ability to perform activity with your normal technique reset
	Ability to participate in your desired sport as long as you'd like reset
	How would you rate your current level of function during SPORTS RELATED ACTIVITIES?	0 50 100 Change the slider above to set a response reset %
	Normal Nearly normal Abnormal Severely abnormal
	How would you rate your current level of function? reset
Please mark a number to represent your pain level in the last month. 0 = none at all , 10 = extreme Tip - If you don't do an activity, imagine how your hip would feel if you had to try it.
	0 1 2 3 4 5 6 7 8 9 10
	Overall how much pain do you have in your hip/groin? reset
	How difficult is it for you to get up and down off the floor/ground? reset
	How difficult is it for you to walk long distances? reset
	How much trouble do you have with grinding, catching or clicking your hip? reset
	How much trouble do you have pushing, pulling, lifting, or carrying heavy objects? reset
	How concerned are you about cutting/changing directions during your sporting or recreational activities? reset
	How much pain do you experience in your hip after activity? reset
	How concerned are you about picking up or carrying children because of your hip? reset
	How much trouble do you have with sexual activity because of your hip? reset
	How much of the time are you aware of the disability in your hip? reset
	How concerned are you about your ability to maintain your desired fitness level? reset
	How much of a distraction is your hip problem? reset
Which of these best describe your hip pain?
	Left hip Right hip
	Total disabled
	Marked, serious limitations
	Moderate, tolerable, make concessions, occasional pain reliever stronger than aspirin or Tylenol
	Mild, no effect on ordinary activity, pain after unusual activity, use aspirin/ibuprofen/Tylenol
	Slight, occasional, no compromise in activity
	None, able to ignore it
How much do you limp while walking?
	Left hip Right hip
	Unable to walk
	Severe
	Moderate
	Slight
	None
Do you need support when walking?
	Left hip Right hip
	Unable to walk
	Walker
	2 Crutches
	2 Canes
	Crutch
	Cane all the time
	Cane for long walks
	None
How far can you walk without stopping because of hip pain?
	Left hip Right hip
	Bed and chair only
	Indoors only
	2-3 blocks
	6 blocks
	Unlimited
How do you go up and down stairs?
	Left hip Right hip
	Not able
	Any method (both feet on each step)
	Normally with banister
	Normally (1 foot on each step)
How do you put on shoes and socks?
	Left hip Right hip
	Unable
	With difficulty
	With ease
How long can you sit in a chair?
	Left hip Right hip
	Unable to sit in any chair 1/2 hour
	High chair, 1/2 hour
	Any chair, 1 hour
Are you able to use public transportation such as a bus or subway if you wanted to?
	Left hip Right hip
	Unable to use
	Able to use
Sports Participation
	In the last 12 months did you participate in competitive sports?	Yes No reset
	How many sports activities?	0 1 2 3 4 reset
	List sport 1
	Level of sport 1 Elite College High School Select/Travel Junior High Other reset
	Other, please specify
	List sport 2
	Level of sport 2 Elite College High school Select/travel Junior high Other reset
	Other, please specify:
	List sport 3
	Level of sport 3 Elite College High school Select/travel Junior high Other reset
	Other, please specify:
	List sport 4
	Level of sport 4 Elite College High school Select/travel Junior high Other reset
	Other, please specify:
How confident you are that you can do them at present, despite the pain 0 = not at all confident, 6 = completely confident
	0 1 2 3 4 5 6
	I can do some form of work, despite the pain reset
	I can live a normal lifestyle, despite the pain reset
When I'm in pain...
	All the time To a great degree To a moderate degree To a slight degree Not at all
	I worry all the time about whether the pain will end reset
	I feel I can't go on reset
	It's terrible and I think it's never going to get any better reset
	It's awful and I feel that it overwhelms me reset
	I feel I can't stand it anymore reset
	I become afraid that the pain will get worse reset
	I keep thinking of other painful events reset
	I anxiously want the pain to go away reset
	I can't seem to keep it out of my mind reset
	I keep thinking about how much it hurts reset
	I keep thinking about how badly I want the pain to stop reset
	There's nothing I can do to reduce the intensity of the pain reset
	I wonder whether something serious may happen reset
Please read each statement and indicate 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.
	Most of the time Good part of time Some of the time Not at all
	I found it hard to wind down reset
	I was aware of dryness in my mouth reset
	I couldn't seem to experience any positive feeling at all reset
	I experienced breathing difficulty (eg, excessively rapid breathing, breathlessness in the absence of physical exertion) reset
	I found it difficult to work up the initiative to do things reset
	I tended to over-react to situations reset
	I experienced trembling (eg, in the hands) reset
	I felt that I was using a lot of nervous energy reset
	I was worried about situations in which I might panic and make a fool of myself reset
	I felt that I had nothing to look forward to reset
	I found myself getting agitated reset
	I found it difficult to relax reset
	I felt down-hearted and blue reset
	I was intolerant of anything that kept me from getting on with what I was doing reset
	I felt I was close to panic reset
	I was unable to become enthusiastic about anything reset
	I felt I wasn't worth much as a person reset
	I felt that I was rather touchy reset
	I was aware of the action of my heart in the absence of physical exertion (eg, sense of heart rate increase, heart missing a beat) reset
	I felt scared without any good reason reset
	I felt that life was meaningless reset
	I feel tense and/or wound up	Most of the time A lot of the time From time to time, occasionally Not at all reset
	I still enjoy the things I used to enjoy	Definitely as much Not quite so much Only a little Hardly at all reset
	I get a sort of frightened feeling as if something awful is about to happen	Very definitely and quite badly Yes, but not too badly A little, but it doesn't worry me Not at all reset
	I can laugh and see the funny side of things	As much as I always could Not quite so much now Definitely not so much now Not at all reset
	Worrying thoughts go through my mind	A great deal of the time A lot of the time From time to time, but not too often Only occasionally reset
	I feel cheerful	Most of the time Sometimes Not often Not at all reset
	I can sit at ease and feel relaxed	Definitely Usually Not often Not at all reset
	I feel as if I am slowed down	Nearly all of the time Very often Sometimes Not at all reset
	I get sort of frightened feeling like butterflies in the stomach	Very often Quite often Occasionally Not at all reset
	I have lost interest in my appearance	Definitely I don't take as much care as I should I may not take quite as much care I take just as much care as ever reset
	I feel restless as I have to be on the move	Very much indeed Quite a lot Not very much Not at all reset
	I look forward with enjoyment to things	As much as I ever did Rather less than I used to Definitely less than I used to Hardly at all reset
	I get sudden feelings of panic	Very often indeed Quite often Not very often Not at all reset
	I can enjoy a good book or radio or TV program	Often Sometimes Not often Very seldom reset
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