iHot

Name

Which hip is this survey about?
Left Right

Patient's d.o.b 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 1919 1918 1917 1916 1915 1914 1913 1912 1911 1910

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?

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

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How difficult is it for you to walk long distances?

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

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

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

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

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

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

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

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

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How much of a distraction is your hip problem?

Final iHot Score is
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