Postpartum Hip Pain Assessment Form
Please answer the following questions to help us better understand your postpartum hip pain and its impact.
When did your hip pain first begin?
*
Where is your hip pain located?
*
Left hip
Right hip
Both hips
Groin area
Outer thigh
Other
How would you rate the average severity of your hip pain in the past week?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
0 is No pain, 10 is Worst pain imaginable
Which activities or factors make your hip pain worse?
Walking
Standing
Sitting
Climbing stairs
Lifting or carrying
Other
Which of the following symptoms do you experience along with hip pain?
Numbness or tingling
Weakness
Swelling
Fever
No associated symptoms
Other
How does hip pain affect your ability to perform daily activities?
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Walking
1
2
3
4
Carrying your baby
5
6
7
8
Climbing stairs
9
10
11
12
Sleeping
13
14
15
16
Personal care (dressing, bathing)
17
18
19
20
What have you tried to relieve your hip pain?
Rest
Ice or heat
Over-the-counter pain medication
Physical therapy
Nothing tried yet
Other
Please provide relevant childbirth history (type of delivery, complications, etc.):
*
Have you previously seen a healthcare provider for this hip pain?
*
Yes
No
If yes, what diagnosis or treatment was provided?
Submit Assessment
Should be Empty: