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Patient Name

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Patient's Date of Birth

Date

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Today's Date

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Please select all sides in which you have had a hip replacement.

INSTRUCTIONS: 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 as indicated by marking the appropriate answer bubble. Mark ONLY ONE box for EACH question. If you are uncertain about how to answer a question, please give the BEST answer you can.
SYMPTOMS: These questions should be answered thinking of your hip symptoms and difficulties during the last week.

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S1. Do you feel grinding, hear clicking or any other type of noise from your hip?

  Never Rarely Sometimes Often Always
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Left:

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S2. Difficulties spreading legs wide apart?

  None Mild Moderate Severe Extreme
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Left:

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S3. Difficulties to stride out when walking?

  None Mild Moderate Severe Extreme
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Left:
STIFFNESS: The following questions concern the amount of joint stiffness you have experienced during the last week in your hip. Stiffness is a sensation of restriction or slowness in the ease with which you move your hip joint.

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S4. How severe is your hip joint stiffness after first wakening in the first morning?

  None Mild Moderate Severe Extreme
Right:
Left:

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S5. How severe is your hip stiffness after sitting, lying or resting later in the day?

  None Mild Moderate Severe Extreme
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Left:
PAIN:

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P1. How often is your hip painful?

  Never Rarely Sometimes Often Always
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Left:
What amount of hip pain have you experienced the last week during the following activities?

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P2. Straightening your hip fully?

  None Mild Moderate Severe Extreme
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Left:

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P3. Bending your hip fully?

  None Mild Moderate Severe Extreme
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Left:

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P4. Walking on a flat surface?

  None Mild Moderate Severe Extreme
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Left:
 
25% of survey complete.

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