Last name* must provide value
First name* must provide value
DOB (Month) January February March April May June July August September October November December
DOB (Day) 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
DOB (Year) YYYY
Sex Male
Female
Today's date Today M-D-Y
Weight (lbs) Pounds
Height (in) 48 in = 4 ft 49 in = 4 ft 1 in 40 in = 4 ft 2 in 51 in = 4 ft 3 in 52 in = 4 ft 4 in 53 in = 4 ft 5 in 54 in = 4 ft 6 in 55 in = 4 ft 7 in 56 in = 4 ft 8 in 57 in = 4 ft 9 in 58 in = 4 ft 10 in 59 in = 4 ft 11 in 60 in = 5 ft 61 in = 5 ft 1 in 62 in = 5 ft 2 in 63 in = 5 ft 3 in 64 in = 5 ft 4 in 65 in = 5 ft 5 in 66 in = 5 ft 6 in 67 in = 5 ft 7 in 68 in = 5 ft 8 in 69 in = 5 ft 9 in 70 in =5 ft 10 in 71 in = 5 ft 11 in 72 in = 6 ft 73 in = 6 ft 1 in 74 in = 6 ft 2 in 75 in = 6 ft 3 in 76 in = 6 ft 4 in 77 in = 6 ft 5 in 78 in = 6 ft 6 in 79 in = 6 ft 7 in 80 in = 6 ft 8 in 81 in = 6 ft 9 in 82 in = 6 ft 10 in 83 in = 6 ft 11 in 84 in = 7 ft
inches
Email* must provide value
MRN
Side of hip problem:* must provide value
Right
Left
Both: Right side more than Left
Both: Left side more than Right
Both side equally
Have you ever had surgery on your hip? Yes No
If YES, what type of surgery or surgeries?
What was the date of your surgery or surgeries?
Have you ever had surgery on your OTHER hip? Yes No
If YES, what type of surgery or surgeries?
What was the date of your surgery or surgeries?
Do you currently smoke? Yes No
Did you ever smoke? Yes No
For how many years did you smoke?
Other comorbidity (if applicable) Please indicate other comorbidity if applicable
Did you receive treatment for this comorbidity? Yes No
Does it limit your daily activities? Yes No
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
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
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 backpacking 9. I sometimes participate in in impact sports such as jogging, tennis, skiing, acrobatics, ballet, heavy labor, or backpacking 8. I regularly participate in very active events such as golf or bowling 7. I regularly participate in active events such as bicycling 6. I regularly participate in moderate activities such as swimming and unlimited housework or shopping 5. I sometimes participate in moderate activities such as swimming and unlimited housework or shopping 4. I regularly participate in mild activities such as walking, limited housework and limited shopping 3. I sometimes participate in mild activities such as walking, limited housework and limited shopping 2. I am mostly inactive: restricted to minimal activities of daily living 1. I am wholly inactive: dependent upon others; cannot leave residence
Do you have pain in the groin? Yes
No
Please identify which side you are referring to Right Left Both sides
Groin pain intensity Pain at night that wakes you up, or pain all the time Pain at rest during the day Pain 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
Do you have pain in the front of your thigh or anterior thigh? Yes
No
Please identify which side you are referring to Right Left Both sides
Anterior thigh pain intensity Pain at night that wakes you up, or pain all the time Pain at rest during the day Pain 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
Do you have pain in the knee? Yes
No
Please identify which side you are referring to Right Left Both sides
Knee pain intensity Pain at night that wakes you up, or pain all the time Pain at rest during the day Pain 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
Do you have pain in the lower back? Yes
No
Lower back pain intensity Pain at night that wakes you up, or pain all the time Pain at rest during the day Pain 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
Do you have pain in the buttock? Yes
No
Please identify which side you are referring to Right Left Both sides
Buttock pain intensity Pain at night that wakes you up, or pain all the time Pain at rest during the day Pain 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
Do you have pain in the back of your thigh or posterior thigh area? Yes
No
Please identify which side you are referring to Right Left Both sides
Posterior thigh pain intensity Pain at night that wakes you up, or pain all the time Pain at rest during the day Pain 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
Do you have pain on the side of your hip or trochanteric area? Yes
No
Please identify which side you are referring to Right Left Both sides
Trochanteric pain intensity Pain at night that wakes you up, or pain all the time Pain at rest during the day Pain 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
Do you have pain in the side of your thigh or lateral thigh area? Yes
No
Please identify which side you are referring to Right Left Both sides
Lateral thigh pain intensity Pain at night that wakes you up, or pain all the time Pain at rest during the day Pain 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
In general, would you say your health is:
Excellent Very good Good Fair Poor
How would you rate your current level of function during SPORTS RELATED ACTIVITIES?
%
In the last 12 months did you participate in competitive sports? Yes
No
How many sports activities? 0 1 2 3 4
List sport 1
Level of sport 1
Elite College High School Select/Travel Junior High Other
Other, please specify
List sport 2
Level of sport 2
Elite College High school Select/travel Junior high Other
Other, please specify:
List sport 3
Level of sport 3
Elite College High school Select/travel Junior high Other
Other, please specify:
List sport 4
Level of sport 4
Elite College High school Select/travel Junior high Other
Other, please specify:
I feel tense and/or wound up Most of the time
A lot of the time
From time to time, occasionally
Not at all
I still enjoy the things I used to enjoy Definitely as much
Not quite so much
Only a little
Hardly at all
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
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
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
I feel cheerful Most of the time
Sometimes
Not often
Not at all
I can sit at ease and feel relaxed Definitely
Usually
Not often
Not at all
I feel as if I am slowed down Nearly all of the time
Very often
Sometimes
Not at all
I get sort of frightened feeling like butterflies in the stomach Very often
Quite often
Occasionally
Not at all
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
I feel restless as I have to be on the move Very much indeed
Quite a lot
Not very much
Not at all
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
I get sudden feelings of panic Very often indeed
Quite often
Not very often
Not at all
I can enjoy a good book or radio or TV program Often
Sometimes
Not often
Very seldom
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