Hip Assessment Quiz | Orthopedists in Lodi

Welcome to the Hip Assessment

There are numerous factors associated with the development of hip pain and mobility disorders. This Hip Assessment will take less than 5 minutes to complete. At the end, our team receives your score and will reach out if a hip consultation with our provider is the next best step for you.

How would you describe the pain you usually have in your hip?*
None
Very Mild
Mild
Moderate
Severe

Have you been troubled by pain from your hip in bed at night?*
None
Only 1 or 2 nights
Some nights
Most nights
Every night

Have you had any sudden, severe pain (shooting, stabbing, or spasms) from your affected hip?*
No days
Only 1 or 2 days
Some days
Most days
Every day

Have you been limping when walking because of your hip?*
Rarely/never
Sometimes or just at first
Often, not just at first
Most of the time
All of the time

For how long have you been able to walk before the pain in your hip becomes severe (with or without a walking aid)?*
No pain for 30 minutes or more
16 to 30 minutes
5 to 15 minutes
Around the house only
Not at all

Have you been able to climb a flight of stairs?*
Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

Have you been able to put on a pair of socks, stockings or tights?*
Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip?*
Not at all painful
Slightly painful
Moderately painful
Very painful
Unbearable

Have you had any trouble getting in and out of a car or using public transportation because of your hip?*
No trouble at all
Very little trouble
Moderate trouble
Extreme difficulty
Impossible to do

Have you had any trouble with washing and drying yourself (all over) because of your hip?*
No trouble at all
Very little trouble
Moderate trouble
Extreme difficulty
Impossible to do

Could you do the household shopping on your own?*
Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

How much has pain from your hip interfered with your usual work, including housework?*
Not at all
A little bit
Moderately
Greatly
Totally

Patient Information

If you are a strong candidate for knee surgery, our office will contact you.
First Name*
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Last Name*
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Height (Feet) *
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Height (Inches) *
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Weight (Pounds) *
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Insurance Type *
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How did you hear about us? *
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Is this work related? *
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Have you had any previous joint replacement surgeries? *
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Birthdate*
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Congratulations!

You've completed the Hip Quiz.

Now, enter your contact information so we can send your score.

Welcome to the Hip Assessment

How would you describe the pain you usually have in your hip?*

Have you been troubled by pain from your hip in bed at night?*

Have you had any sudden, severe pain (shooting, stabbing, or spasms) from your affected hip?*

Have you been limping when walking because of your hip?*

For how long have you been able to walk before the pain in your hip becomes severe (with or without a walking aid)?*

Have you been able to climb a flight of stairs?*

Have you been able to put on a pair of socks, stockings or tights?*

After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip?*

Have you had any trouble getting in and out of a car or using public transportation because of your hip?*

Have you had any trouble with washing and drying yourself (all over) because of your hip?*

Could you do the household shopping on your own?*

How much has pain from your hip interfered with your usual work, including housework?*

Patient Information

Congratulations!