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TOTAL SHOULDER REPLACEMENT

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HOOS HIP SURVEY

Today's date:

Date of birth:

Name:

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.

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

NeverRarelySometimesOftenAlways

S2. Difficulties spreading legs wide apart

NoneMildModerateSevereExtreme

S3. Difficulties to stride out when walking

NoneMildModerateSevereExtreme

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 our hip joint.

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

NoneMildModerateSevereExtreme

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

NoneMildModerateSevereExtreme

Pain

P1. How often is your hip painful?

NeverMonthlyWeeklyDailyAlways

What amount of hip pain have you experienced the last week during the following activities?

P2. Straightening your hip fully

NoneMildModerateSevereExtreme

What amount of hip pain have you experienced the last week during the following
activities?

P3. Bending your hip fully

NoneMildModerateSevereExtreme

P4. Walking on a flat surface

NoneMildModerateSevereExtreme

P5. Going up or down stairs

NoneMildModerateSevereExtreme

P6. At night while in bed

NoneMildModerateSevereExtreme

P7. Sitting or lying

NoneMildModerateSevereExtreme

P8. Standing upright

NoneMildModerateSevereExtreme

P9. Walking on a hard surface (asphalt, concrete, etc.)

NoneMildModerateSevereExtreme

P10. Walking on an uneven surface

NoneMildModerateSevereExtreme

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.

A1. Descending stairs

NoneMildModerateSevereExtreme

A2. Ascending stairs

NoneMildModerateSevereExtreme

A3. Rising from sitting

NoneMildModerateSevereExtreme

A4. Standing

NoneMildModerateSevereExtreme

A4. Standing

NoneMildModerateSevereExtreme

For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your hip.

A5. Bending to the floor/pick up an object

NoneMildModerateSevereExtreme

A6. Walking on a flat surface

NoneMildModerateSevereExtreme

A7. Getting in/out of car

NoneMildModerateSevereExtreme

A8. Going shopping

NoneMildModerateSevereExtreme

A9. Putting on socks/stockings

NoneMildModerateSevereExtreme

A10. Rising from bed

NoneMildModerateSevereExtreme

A11. Taking off socks/stockings

NoneMildModerateSevereExtreme

A12. Lying in bed (turning over, maintaining hip position)

NoneMildModerateSevereExtreme

A13. Getting in/out of bath

NoneMildModerateSevereExtreme

A14. Sitting

NoneMildModerateSevereExtreme

A15. Getting on/off toilet

NoneMildModerateSevereExtreme

A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)

NoneMildModerateSevereExtreme

A17. Light domestic duties (cooking, dusting, etc)

NoneMildModerateSevereExtreme

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.

SP1. Squatting

NoneMildModerateSevereExtreme

SP2. Running

NoneMildModerateSevereExtreme

SP3. Twisting/pivoting on loaded leg

NoneMildModerateSevereExtreme

SP4. Walking on uneven surface

NoneMildModerateSevereExtreme

Quality of Life

Q1. How often are you aware of your hip problem?

NeverMonthlyWeeklyDailyConstantly

Q2. Have you modified your life style to avoid activities potentially damaging to your hip?

Not at allMildlyModeratelySeverelyTotally

Q3. How much are you troubled with lack of confidence in your hip?

Not at allMildlyModeratelySeverelyTotally

Q4. In general, how much difficulty do you have with your hip?

NoneMildModerateSevereExtreme

Email:

Hip dysfunction and Osteoarthritis Outcome Score for Joint Replacement (HOOS, JR.)

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 unsure about how to answer a question, please give the best answer you can.