• Total Joint Study Questionnaire - Total Hip Replacement - Initial Questionnaire

    If you had a total knee replacement, please let your medical assistant know you need the other form
  • Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date of Surgery (If Known)
     - -
    2 digit month, 2 digit day, 4 digit year
  • Surgery Site

  • Numeric Pain Rating Scale

  •   

  • Hoos Jr.

  • Pain

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

  • 1. Going up or down stairs
  • 2. Walking on an uneven surface

  • 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.

  • 3. Rising from sitting
  • 4. Bending to floor/picking up an object
  • 5. Lying in bed (turning over, maintaining hip position)
  • 6. Sitting

  • VR-12

  • 1. In general, would you say your health is:

  • 2. The following items are about activities you might do during a typical day. Does your health now limit you in these activities? If so, how much?

  • a. Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling, or playing golf
  • b. Climbing several flights of stairs

  • 3. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?

  • a. Accomplished less than you would like
  • b. Were limited in the kind of work or activities

  • 4. During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed or anxious)?

  • a. Accomplished less than you would like
  • b. Didn't do work or other activities as carefully as usual
  • 5. During the past 4 weeks, how much did pain interfere with your normal work (including both work outside the home and housework)?

  • These questions are about how you feel and how things have been with you during the past 4 weeks. For each question, please give the one answer that comes closest to the way you have been feeling.

     

    6. How much of the time during the past 4 weeks:

  • a. Have you felt calm and peaceful?
  • b. Did you have a lot of energy?
  • c. Have you felt downhearted and blue?
  • 7. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.)?

  • Now, we’d like to ask you some questions about how your health may have changed.

  • 8. Compared to one year ago, how would you rate your physical health in general now?
  • 9. Compared to one year ago, how would you rate your emotional problems (such as feeling anxious, depressed or irritable) in general now?
  • Should be Empty: