scott-faucett_logo Our new practice location has moved to below address

The Orthopaedic Center, P.A.
2112 F Street NW, Suite 305
Washington D.C. 20037

Phone: (202) 770-1447
Appointments: (202) 912-8480
Fax: (202) 912-8484

Click here for more information

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iHot12

Date of completion
Name
Which hip is this survey about? Left Right
Patient's d.o.b

INSTRUCTIONS

These Questions ask about the problems you may be experiencing in your hip, how these problems affect your life, and the emotions you may feel because of these problems. Please indicate the severity by marking the line below each question using the slider.

    TIP If you don't do an activity, imagine how your hip would feel if you had to try it.
  • If you put a mark on the far left, it means that you feel you are significantly impaired.

  • If the mark is placed in the middle of the line, this indicates that you are moderately disabled, or in other words, between the extremes of 'significantly impaired' and 'no problems at all'. It is important to put your mark at either end of the line if the extreme descriptions accurately reflect your situation.

Overall, How much pain do you have in your hip/groin?

Extremely pain
No pain at all





How difficult is it for you to get up and down off the floor/ground?

Extremely difficult
Not difficult at all





How difficult is it for you to walk long distances?

Extremely difficult
Not difficult at all





How much trouble do you have with grinding, catching or clicking in your hip?

Severe trouble
Not trouble at all





How much trouble do you have pushing, pulling, lifting or carrying heavy objects?

Severe trouble
Not trouble at all





How concerned are you about cutting/changing directions during your sport or recreational activities?

Extreme concerned
Not concerned at all





How much pain do you experience in your hip after activity?

Extreme pain
No pain at all





How concerned are you about picking up or carrying children because of your hip?

Extremely concerned
Not concerned at all





How much trouble do you have with sexual activity because of your hip?

Severe trouble
Not trouble at all





How much of the time you are aware of the disability in your hip?

Constantly aware
Not aware at all





How concerned are you about your ability to maintain your desired fitness level?

Extremely concerned
Not concerned at all





How much of a distraction is your hip problem?

Extreme distraction
No distraction at all



Final iHot Score is

To save this data please print or

Nb: This page cannot be saved due to patient data protection so please print the filled in form before closing the window.
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