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Symptoms These questions should be answered thinking of your hip symptoms during the last week.
Do you feel grinding, hear clicking or any type of noise when your hip moves?
---NeverRarelySometimesOftenAlways
Difficulties spreading your legs wide apart? ---NeverRarelySometimesOftenAlways
Difficulties to stride out when walking? ---NeverRarelySometimesOftenAlways
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.
How severe is your hip joint stiffness after first waking up in the morning? ---NoneMildModerateSevereExtreme
How severe is your hip stiffness after sitting, lying or resting later in the day? ---NoneMildModerateSevereExtreme
Pain
How often is your hip painful? ---NeverMonthlyWeeklyDailyAlways
Straightening your hip fully? ---NoneMildModerateSevereExtreme
Bending your hip fully? ---NoneMildModerateSevereExtreme
Walking on a flat surface? ---NoneMildModerateSevereExtreme
Going up or down stairs? ---NoneMildModerateSevereExtreme
At night in bed? ---NoneMildModerateSevereExtreme
Sitting or lying? ---NoneMildModerateSevereExtreme
Standing upright? ---NoneMildModerateSevereExtreme
Walking on a hard surface (tarmac, concrete, etc.)? ---NoneMildModerateSevereExtreme
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:
Descending stairs? ---NoneMildModerateSevereExtreme
Ascending stairs? ---NoneMildModerateSevereExtreme
Rising from sitting? ---NoneMildModerateSevereExtreme
Standing ---NoneMildModerateSevereExtreme
Bending to floor/pick up an object? ---NoneMildModerateSevereExtreme
Getting in/out of a car? ---NoneMildModerateSevereExtreme
Going shopping? ---NoneMildModerateSevereExtreme
Putting on socks/tights? ---NoneMildModerateSevereExtreme
Rising from bed? ---NoneMildModerateSevereExtreme
Taking off socks/tights? ---NoneMildModerateSevereExtreme
Lying in bed? (turning over, maintaining hip position) ---NoneMildModerateSevereExtreme
Getting in/out of bath? ---NoneMildModerateSevereExtreme
Sitting? ---NoneMildModerateSevereExtreme
Getting on/off the toilet? ---NoneMildModerateSevereExtreme
Heavy domestic duties? (moving heavy boxes, scrubbing floors etc.) ---NoneMildModerateSevereExtreme
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:
Squatting? ---NoneMildModerateSevereExtreme
Running? ---NoneMildModerateSevereExtreme
Jumping? ---NoneMildModerateSevereExtreme
Twisting/Pivoting on loaded leg? ---NoneMildModerateSevereExtreme
Walking on uneven surface? ---NoneMildModerateSevereExtreme
Quality of Life
How often are you aware of your hip problem? ---NeverMonthlyWeeklyDailyConstantly
Have you modified your lifestyle to avoid potentially damaging activities to your hip? ---Not at allMildlyModeratelySeverelyTotally
How much are you troubled with your lack of confidence in your hip? ---NoneMildlyModeratelySeverelyExtremely
In general, how much difficulty do you have with your hip? ---NoneMildModerateSevereExtreme
Type of Enquiry ---Quotation RequestAppointment RequestInformation Request
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