HOOS Form

HOOS

Hip Disability and Osteoarthritis Outcome Score (HOOS)

First Name(Required)

Last Name(Required)

Patient Date of Birth(Required)

Today's Date

Instructions: This survey asks for your view about your hip. It helps us understand how you feel and how well you are able to do your usual activities. Please answer every question by circling the response that best describes your experience in the last week. If you are unsure, just give the answer that seems closest.

0 = None, 1 = Mild, 2 = Moderate, 3 = Severe, 4 = Extreme

Symptoms & Stiffness

1. Do you feel grinding, clicking or any other type of noise from your hip?(Required)

2. Difficulties spreading legs wide apart(Required)

3. Difficulties striding out when walking(Required)

4. How severe is your hip stiffness after first waking in the morning?(Required)

5. How severe is your hip stiffness after sitting, lying, or resting later in the day?(Required)

Pain

1. How often is your hip painful?(Required)

2. Straightening your hip fully(Required)

3. Bending your hip fully(Required)

4. Walking on a flat surface(Required)

5. Going up or down stairs(Required)

6. At night while in bed(Required)

7. Sitting or lying(Required)

8. Standing upright(Required)

9. Walking on a hard surface (asphalt, concrete, etc.)(Required)

10. Walking on an uneven surface(Required)

Function - Daily Living

1. Descending stairs(Required)

2. Ascending stairs(Required)

3. Rising from sitting(Required)

4. Standing upright for long periods(Required)

5. Bending to the floor / picking up an object(Required)

6. Walking on flat surface(Required)

7. Getting in / out of car(Required)

8. Going shopping(Required)

9. Putting on socks/stockings(Required)

10. Rising from bed(Required)

11. Taking off socks/stockings(Required)

12. Lying in bed (turning over, maintaining hip position)(Required)

13. Getting in/out of bath(Required)

14. Sitting for long periods(Required)

15. Getting on/off toilet(Required)

16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc.)(Required)

17. Light domestic duties (cooking, dusting, etc.)(Required)

Sports & Recreation Activities

1. Squatting(Required)

2. Running(Required)

3. Twisting / pivoting on loaded leg(Required)

4. Walking on uneven surface(Required)

Quality of Life

1. How often are you aware of your hip problem?(Required)

2. Have you modified your lifestyle to avoid activities potentially damaging to your hip?(Required)

3. How much are you troubled with lack of confidence in your hip?(Required)

4. In general, how much difficulty do you have with your hip?(Required)

Dr. Aaron Kovaleski, MD

Kendra Payne, FNP-BC

Kyle Odvody, MS, FNP-BC

Greg Charleston, AGACNP-BC

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