hip pain assessment form

date I - pain or discomfort a.) during nocturnal bedrest

only on movement or in certain positions without movement

name

points

1 2 1 2 1 1 2 1

b.) duration of morning stiffness or pain after getting up

less than 15 min 15 min or more

c.) remaining standing for 30 minutes increases pain d.) pain on walking
only after walking some distance early after starting

e.) pain or discomfort if in sitting position for 2 hours

II - maximum distance walked

more than 1/2 mile, but limited about 1/2 mile (about 15 min) from 500 yards to 1/2 mile (about 8-15 min) from 300 to 500 yards from 100 to 300 yards less than 100 yards with one walking stick or crutch with two walking sticks or crutches

1 2 3 4 5 6 +1 +2

III - activities of daily living

can can can can you you you you put on socks by bending forward? pick up an object from the floor? go up and down a standard flight of stairs? get into and out of a car? easily with difficulty impossible

0 0 0 0

to to to to

2 2 2 2

point score:

0 1 (or 0.5 or 1.5) 2

[Cont.]

IV - pain numerical rating scale

on average how bad has your pain been over the last week? circle appropriate number:

no pain 0 100 10 20 30 40 50 60 70 80

pain as bad as it could be 90

V - self-assessment of result
how do you feel in comparison with your last visit? please tick appropriate box: much better a little worse better worse a little better much worse same

VI - self-assessment of handicap
how do you rate the handicap you experience? please tick appropriate box: mild very severe moderate almost unbearable severe

Lequesne MG et al Indexes of severity for osteoarthritis of the hip and knee Scand J Rheumatol 1987; suppl 65: 85-9