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Hip Survey Form


Last Name : SSN :
First Name :
Address : Home Phone :
City : State : Zipcode : Workphone :


1. In the past month what has the intensity of your HIP PAIN been like? (Choose only ONE per hip)
 
Right Left  
None/ I have no pain in my hip.
I have slight pain Occasionally.
I have slight pain Frequently.
I have significant pain after certain activities, which requires light medication (aspirin, motrin, etc.) occasionally.
I have significant pain with most activities, but no pain or minimum pain at rest. I take light medication frequently.
I have pain all of the time, but it is bearable. I take strong medication occasionally and light medication frequently.
I have pain all of the time, which is UNbearable. I take strong medication (Vicodin, Codeine, etc.) frequently.

2. The pain that I am having in my hip is located...
 
Right Left (Choose ONE per hip)
In Front / Groin Region.
In the Back / Buttocks Region
On the Side.
Any combination of the above.
I am Not having Pain
Other:
3. Do you have Thigh Pain? (Choose ONE per hip)
 
Right Left (Choose ONE per hip)
No thigh pain.
Some pain; no medication.
A lot of pain; some medication.
Some pain standing, worse walking
Pain most of the time; limits activities.

If Other, Please Specify :

4. Currently, I am able to walk... (Choose ONE)
 
Without any sort of walking aid.
With (1) Cane
With (1) Crutch
With (2) Canes
With (2) Crutches
With a Walker
5. Generally, how far can you walk comfortably before you must top to rest? (Choose ONE)
 
More than 6 Blocks.
About 4-6 Blocks.
About1-3 Blocks.
Less than 1 Block
Only from my bed to a chair or bathroom.
I am unable to Walk.

6. The medication I am taking for my hip pain is...

Strength?        How Often?


7. Please choose only ONE of the following statements that best describes your ability to WALK.
 
I am Unrestricted. I Do Not Use Support, and I Do Not Limp.
I Do Not Use Support, but I do have a Limp, OR, I use (1) Support without a Limp.
I Do Not Use Support for (1) Block, OR, I Use (1) Support up to (6) blocks, OR, I use bilateral support without restriction.
I Do Not Use Support because I am house bound, OR, I use bilateral support for a Short Distance.
I am Wheelchair bound, OR I transfer activities with a Walker.
I am Bedridden.

8. I can put on shoes and socks...
 
With ease.
With difficultly.
I am unable to put on shoes or socks without assistance
9. I am able to climb stairs...
 
Foot over foot without a banister.
Foot over foot using a banister.
Stairs in any manner.
unable to climb stairs.

10. I am able to sit...
 
Comfortable in any chair for one hour.
Comfortable in a high chair for 1/2 hour.
Unable to sit comfortably in any chair
11. I am able to enter Public Transportation...
 
Yes
No

12. Limp
 
None
Slight
Moderate
Severe
Unable to walk
13. If I had to, I could Sometimes...
 
Function without Restriction. 8 hr work + sports
Function with a little Restriction. 6 hr work + occasional sport
Do Most of the housework/Shopping. On feet 4 hours
Do Limited housework/Shopping
None of the above

14. Please choose only ONE of the following statements which best describes your MAXIMUM Activity Level.
 
I Regularly participate in jogging and/or tennis, skiing, aerobics, backpacking, heavy labor.
I Sometimes participate in jogging and/or tennis, skiing, aerobics, backpacking, heavy labor.
I Regularly participate in bicycling.
I Regularly participate in bowling and/or golf.
I Regularly participate in swimming and/or shopping, unlimited work around the house.
I Regularly participate in walking, limited work around the house/shopping.
I Sometimes participate in walking, limited work around the house/shopping.
I am VERY RESTRICTED and I am only able to do MINIMUM ACTiVITIES.
I require assistance for most activities and generally do not leave the house.



SF12 Health Survey
(Standard)
This questionnaire asks for your views about your health.
This Information will help us keep track of how you feel and
how well you are able to do your usual activities.
1.
In general, i would say my health is...
Excellent
Very Good
Good
Fair
Poor
The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

2.
Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf.
Yes, limited a lot
Yes, limited a little
No, not limited at all

3.
Climbing several flights of stairs.
Yes, limited a lot
Yes, limited a little
No, not limited at all

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

4.
Accomplished less than you would like?
Yes
No

5.
Were limited in the kind of work or other activities?
Yes
No

During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your emotional problems, such as feeling depressed or anxious?
6.
Accomplished less than you would like?
Yes
No

7.
Didn't do work or other activities as carefully as usual?
Yes
No

8.
During the past 4 weeks, how much did pain interfere with your normal work 9including both work outside the home and housework)?
Not at all
A little bit
Moderately
Quite a bit
Extermely
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...
9. ...have you felt calm and peaceful?
 
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time
10. ...did you have a lot of energy?
 
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time

11. ...have you felt downhearted and blue?
 
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time

12. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with you social activities (like visiting friends, relative, etc)?
 
All of the time
Most of the time
A good bit of the time
Some of the time
A little of the time
None of the time

Sports Activity Survey
List all the physical activities you have been participating in on a regular basis over the past 6 months.
Have you had a revision?
Yes
No
Please fill out one activity per box.

ACTIVITY#1 Activity List :
  If Other, Please Specify:

  Frequency (# of times per month)
 
1-4 times/month
5-8 times/month
9-12 times/month
>12 times/month
  Duration per session
 
0-30 minuts
30-60 minutes
60-120 minutes
>120 minutes
  Intensity (check one in each field)
 
Competitive
Recreational
Beginner
Intermediate
Advanced
Expert

ACTIVITY#2 Activity List :
  If Other, Please Specify:

  Frequency (# of times per month)
 
1-4 times/month
5-8 times/month
9-12 times/month
>12 times/month
  Duration per session
 
0-30 minuts
30-60 minutes
60-120 minutes
>120 minutes
  Intensity (check one in each field)
 
Competitive
Recreational
Beginner
Intermediate
Advanced
Expert

ACTIVITY#3 Activity List :
  If Other, Please Specify:

  Frequency (# of times per month)
 
1-4 times/month
5-8 times/month
9-12 times/month
>12 times/month
  Duration per session
 
0-30 minuts
30-60 minutes
60-120 minutes
>120 minutes
  Intensity (check one in each field)
 
Competitive
Recreational
Beginner
Intermediate
Advanced
Expert
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