Hip Quiz

Clinician’s name (or ref) June 13, 2019
Date of completionPatient’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.