Outcome Registry

Hip Arthroscopy Outcome Assessment

Fields marked (*) are compulsory

First Name *

Last Name *

Email *

Phone Number *

Date of Birth *

Age *

Date of Hip Arthroscopy *

Follow-Up Date from Hip Arthroscopy *

Since your Hip Arthroscopy, how would you rate your overall physical ability? *

Harris Hip Score

1. Describe the pain in each of your hips:
	Left	Right
None
Slight pain or occasional pain
Mild, no effect on ordinary activity, pain after unusual activity, use aspirin or similar medication.
Moderate, pain that required medicine stronger than aspirin / similar medication. I am active but have had to make modifications and/or give up some activities because of pain.
Marked or servere pain that limits activity and requires pain medicine frequently.
Severe pain even in bed. I am totally disabled.

2. How do you climb stairs?
Normally (foot over foot without use of banister).
Need a banister, cane or crutch.
Severe trouble climbing stairs.
Unable to climb stairs.

3. Are you physically able to use public transportation (bus, etc…)?

Yes No

4. In terms of sitting in a chair, are you:
Comfortable in any chair for one hour.
Comfortable in a high chair for one-half hour.
Unable to sit comfortably in any chair.

5. In terms of putting on your sock and shoe on each side?
	Left	Right
Can put on sock and tie shoe easily
Can put on sock and tie shoe with difficulty.
Unable to put on sock or tie shoe.

6. Amount and type of support used:
None.
Single cane for long walks.
Single cane most of the time.
One crutch.
Two canes.
Two crutches.
Not able to walk at all.

7. Distance you can walk (this should be judged with the aid of support if you use any):
Unlimited.
Six blocks.
Two or three blocks.
Indoors only.
Bed to chair.
Not able to walk at all.

8. How much do you limp on each leg? (This should be judged at the end of your longest walk using the amount of support indicated in the questions above).
	Left	Right
None.
Slight.
Moderate.
Severe.

Bethesda Survey
Question: How much pain do you have?

1. Walking on a flat surface?

None Mild Moderate Severe Extreme

2. Going up or down Stairs?

None Mild Moderate Severe Extreme

3. At night while in bed?

None Mild Moderate Severe Extreme

4. Sitting or lying?

None Mild Moderate Severe Extreme

5. Standing upright?

None Mild Moderate Severe Extreme

The following 4 questions concern the symptoms that you are currently experiencing in the hip that you are having evaluated today. For each situation indicate the answer that most reflects the symptoms experienced in the past 48 hours. (Please click on one radio button in each row.)

Question: How much trouble do you have with -

1. Catching or locking of your hip?

None Mild Moderate Severe Extreme

2. Your hip giving out on you?

None Mild Moderate Severe Extreme

3. Stiffness in your hip?

None Mild Moderate Severe Extreme

4. Decreased motion in your hip?

None Mild Moderate Severe Extreme

The following 5 questions concern your physical function. For each of the following activities, please indicate the response that accurately reflects the difficulty that you have experienced in the past 48 hours because of your hip pain. (Please click on one radio button in each row.)

Question: What degree of difficulty do you have with-

1. Descending stairs?

None Mild Moderate Severe Extreme

2. Ascending stairs?

None Mild Moderate Severe Extreme

3. Rising from sitting?

None Mild Moderate Severe Extreme

4. Putting on socks/stockings?

None Mild Moderate Severe Extreme

5. Rising from bed?

None Mild Moderate Severe Extreme

The following 6 questions concern your ability to participate in certain types of activities. For each of the following activities, please indicate the response that most accurately reflects the difficulty that you have experienced in the past month because of your hip pain. If you do not participate in a certain type of activity, please estimate how much trouble your hip would cause you if you had to perform that type of activity. Please click on the one radio button that best describes your situation.

Question: How much trouble does your hip cause you when you participate in -

1. High demand sports involving sprinting or cutting (for example, football, basketball, tennis
and exercise aerobics)?

None Mild Moderate Severe Extreme

2. Low Demand sports (for example, golfing and bowling)?

None Mild Moderate Severe Extreme

3. Jogging for exercise?

None Mild Moderate Severe Extreme

4. Walking for exercise?

None Mild Moderate Severe Extreme

5. Heavy household duties (for example, lifting firewood and moving furniture)?

None Mild Moderate Severe Extreme

6. Light household duties (for example, cooking, dusting, vacuuming and doing laundry)?

None Mild Moderate Severe Extreme

Enter the code as it is shown:*

© Thomas Youm MD Orthopaedic Hip Knee Shoulder Surgeon Hip Arthroscopy New York NY
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