HOOS-12 HIP SURVEY

Please fill-out the form below or download the PDF here.

Download HOOS-12 SURVEY HERE

Participant Details

Please complete all sections
Name(Required)
MM slash DD slash YYYY

Pain

INSTRUCTIONS: This survey asks for your views about your hip. Answer every question by marking the appropriate box, only one box for each question. If you are unsure about how to answer a question, please give the best answer you can.
1. How often do you experience hip pain?(Required)

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

2. Walking on a flat surface(Required)
3. Going up or down stairs(Required)
4. Sitting or lying(Required)

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.
5. Rising from sitting(Required)
6. Standing(Required)
7. Getting in/out of a car(Required)
8. Walking on an uneven surface(Required)
9. How often are you aware of your hip problem?(Required)

Quality of Life

10. Have you modified your life style to avoid potentially damaging activities to your(Required)
11. How much are you troubled with lack of confidence in your hip?(Required)
12. In general, how much difficulty do you have with your hip?(Required)(Required)
COMPASS REHAB

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