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Hip Quiz

Clinician's name (or ref)




Date of completion

Patient's name (or ref)

 
Please answer the following 12 multiple choice questions.
During the past 4 weeks......
1. How would you describe the pain you usually have in your hip?   7. Have you been able to put on a pair of socks, stockings or tights?
None   Yes, easily
Very mild   With little difficulty
Mild   With moderate difficulty
Moderate   With extreme difficulty
Severe   No, impossible
 
2. Have you been troubled by pain from your hip in bed at night?   8. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip?
No nights   Not at all painful
Only 1 or 2 nights   Slightly painful
Some nights   Moderately painful
Most nights   Very painful
Every night   Unbearable
 
3. Have you had any sudden, severe pain (shooting, stabbing, or spasms) from your affected hip?   9. Have you had any trouble getting in and out of a car or using public transportation because of your hip?
No days   No trouble at all
Only 1 or 2 days   Very little trouble
Some days   Moderate trouble
Most days   Extreme difficulty
Every day   Impossible to do
 
4. Have you been limping when walking because of your hip?   10. Have you had any trouble with washing and drying yourself (all over) because of your hip?
Rarely/never   No trouble at all
Sometimes or just at first   Very little trouble
Often, not just at first   Moderate trouble
Most of the time   Extreme difficulty
All of the time   Impossible to do
 
5. For how long have you been able to walk before the pain in your hip becomes severe (with or without a walking aid)?   11. Could you do the household shopping on your own?
No pain for 30 minutes or more   Yes, easily
16 to 30 minutes   With little difficulty
5 to 15 minutes   With moderate difficulty
Around the house only   With extreme difficulty
Not at all   No, impossible
 
6. Have you been able to climb a flight of stairs?   12. How much has pain from your hip interfered with your usual work, including housework?
Yes, easily   Not at all
With little difficulty   A little bit
With moderate difficulty   Moderately
With extreme difficulty   Greatly
No, impossible   Totally

Hip Quiz Score is:


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Interpreting the Score
Score 0 to 19
May indicate severe hip arthritis. It is highly likely that you may well require some form of surgical intervention, contact your family physician for a consult with an Orthopaedic Surgeon.
Score 20 to 29

May indicate moderate to severe hip arthritis. See your family physician for an assessment and x-ray. Consider a consult with an Orthopaedic Surgeon.

Score 30 to 39

May indicate mild to moderate hip arthritis. Consider seeing you family physician for an assessment and possible x-ray. You may benefit from non-surgical treatment, such as exercise, weight loss, and /or anti-inflammatory medication

Score 40 to 48

May indicate satisfactory joint function. May not require any formal treatment.

Reference for Score:  Dawson J, Fitzpatrick R, Carr A, Murray D. Questionnaire on the perceptions of patients about total hip replacement. J Bone Joint Surg Br. 1996 Mar;78(2):185-90. Link