Weiss Hospital

Complete a Pre-Surgical Hip Form

Step 4: Complete a Pre-Surgical Hip Form for your Pre-Op or Clinic Visit

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 by ticking the appropriate box, 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.
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.
PAIN
What amount of hip pain have you experienced 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.
For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your hip.
FUNCTION, SPORTS AND RECREATIONAL ACTIVITIES: The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your hip.
QUALITY OF LIFE