Home » Patient Info » Patient Forms » Hip disability Osteoarthritis Outcome Score (HOOS) Hip disability Osteoarthritis Outcome Score (HOOS) Today's date Clinician's name (or ref): Patient's name (or ref): Patient's Date of Birth : Date 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Year 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910 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. If you are unsure about how to answer a question, please give the best answer you can. Symptoms - These questions should be answered thinking of your hip symptoms during the last week. S1. Do you feel grinding, hear clicking or any other type of noise from you hip? Never Rarely Sometimes Often Always S2. Difficulties spreading legs wide apart None Mild Moderate Severe Extreme S3. Difficulties to stride out when walking None Mild Moderate Severe Extreme 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. S4. How severe is your hip joint stiffness after first wakening in the morning? None Mild Moderate Severe Extreme S5. How severe is your hip stiffness after sitting, lying or resting later in the day? None Mild Moderate Severe Extreme Subtotal: Pain P1. How often is your hip painful? Never Monthly Weekly Daily Always What amount of hip pain have you experienced the last week during the following activities? P2. Straightening your hip fully None Mild Moderate Severe Extreme P3. Bending your hip fully None Mild Moderate Severe Extreme P4. Walking on flat surface None Mild Moderate Severe Extreme P5. Going up or down stairs None Mild Moderate Severe Extreme P6. At night while in bed None Mild Moderate Severe Extreme P7. Sitting or lying None Mild Moderate Severe Extreme P8. Standing upright None Mild Moderate Severe Extreme P9. Walking on a hard surface (asphalt, concrete, etc) None Mild Moderate Severe Extreme P10. Walking on an uneven surface None Mild Moderate Severe Extreme Subtotal: 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. Al. Descending stairs None Mild Moderate Severe Extreme A2. Ascending stairs None Mild Moderate Severe Extreme A3. Rising from sitting None Mild Moderate Severe Extreme A4. Standing None Mild Moderate Severe Extreme A5. Bending to floor/pick up an object None Mild Moderate Severe Extreme A6. Walking on flat surface None Mild Moderate Severe Extreme A7. Getting in/out of car None Mild Moderate Severe Extreme A8. Going shopping None Mild Moderate Severe Extreme A9. Putting on socks/stockings None Mild Moderate Severe Extreme A10. Rising from bed None Mild Moderate Severe Extreme A11. Taking off socks/stockings None Mild Moderate Severe Extreme A12. Lying in bed (turning over, maintaining hip position) None Mild Moderate Severe Extreme A13. Getting in/out of bath None Mild Moderate Severe Extreme A14. Sitting None Mild Moderate Severe Extreme A15. Getting on/off toilet None Mild Moderate Severe Extreme A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) None Mild Moderate Severe Extreme A17. Light domestic duties (cooking, dusting, etc) None Mild Moderate Severe Extreme Subtotal: 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 None Mild Moderate Severe Extreme SP2. Running None Mild Moderate Severe Extreme SP3. Twisting/pivoting on your injured knee None Mild Moderate Severe Extreme SP4. Walking on uneven surface None Mild Moderate Severe Extreme Subtotal: Quality of Life Q1. How often are you aware of your hip problem? Never Monthly Weekly Daily Constantly Q2. Have you modified your life style to avoid potentially damaging activities to your hip? Not at all Mildly Moderately Severely Totally Q3. How much are you troubled with lack of confidence in your hip? Not at all Mildly Moderately Severely Extremely Q4. In general, how much difficulty do you have with your hip? None Mild Moderate Severe Extreme Subtotal: The HOOS Hip SurveyScore is To send this data to doctor please click submit
