PROBLEMS WITH YOUR HIP ?
Your Details	
GP Practice:	
Organisation Name 
	GP:	Usual GP Full Name 	
Your Name:	
Full Name 
	Your Date of Birth:	Date of Birth 	
Your Address:	
Home Full Address (single line) 

	Your Contact Telephone Number:	Patient Home Telephone 	
Your NHS Number:	NHS Number 	Date You Completed This Questionnaire:	

During the Past 4 weeks…					Tick one box for each question	
1	How would you describe the pain you usually have from your hip?

None			Very Mild		Mild		Moderate		Severe
											
(4)			(3)			(2)		(1)			(0)	
2	Have you had any trouble with washing and drying yourself (all over) because of your hip?

No Trouble		Very Little		Moderate 	Extreme		Impossible
At All			Trouble		Trouble	Difficulty		To Do
											
(4)			(3)			(2)		(1)			(0)	
3	Have you had any trouble getting in and out of a car or using public transport because of your hip? (whichever you would normally use)

No Trouble		Very Little		Moderate 	Extreme		Impossible
At All			Trouble		Trouble	Difficulty		To Do
											
(4)			(3)			(2)		(1)			(0)	
4	For how long have you been able to walk before pain from your hip becomes severe? (with or without a walking aid like a stick/frame)

No Pain/		16 to 30		5 to 15	 	Around the		Not At All
More Than 30		Minutes		Minutes	House Only		Pain Severe
Minutes										When Walking
											
(4)			(3)			(2)		(1)			(0)	
5	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		Slightly			Moderately 	Very 			Unbearable
Painful			Painful			Painful		Painful			
											
(4)			(3)			(2)		(1)			(0)
Please Turn Over – More Questions Overleaf…	
6	Have you been limping when walking, because of your hip?

Rarely/			Sometimes		Often, Not 	Most Of		All Of 
Never			Or Just At		Just At		The Time		The Time				First			First
											
(4)			(3)			(2)		(1)			(0)	
7	Have you had any sudden, severe pain (shooting, stabbing or spasms) from your affected hip?

No			Only 1	or 2	Some		 	Most			Every
Days			Days		Days			Days			Day
											
(4)			(3)		(2)			(1)			(0)	
8	Have you been troubled by pain from your hip in bed at night?

No			Only 1	or 2	Some		 	Most			Every
Nights			Nights		Nights			Nights			Night
											
(4)			(3)		(2)			(1)			(0)	
9	How much has pain from your hip interfered with your usual work (including housework)?

Not At			A Little		Moderately	 	Greatly			Totally
All			Bit					
											
(4)			(3)		(2)			(1)			(0)	
10	Have you been able to put on a pair of socks, stockings or tights?

Yes			With Little	With Moderate	 	With Extreme		No
Easily			Difficulty	Difficulty		Difficulty		Impossible
											
(4)			(3)		(2)			(1)			(0)	
11	Could you do the household shopping on your own?

Yes			With Little	With Moderate	 	With Extreme		No
Easily			Difficulty	Difficulty		Difficulty		Impossible
											
(4)			(3)		(2)			(1)			(0)	
12	Could you climb up one flight of stairs?

Yes			With Little	With Moderate	 	With Extreme		No
Easily			Difficulty	Difficulty		Difficulty		Impossible
											
(4)			(3)		(2)			(1)			(0)	
Thank you for completing this questionnaire, please give this sheet to 
the Physiotherapist or Reception/your GP at your practice

For Practice Use Only	
Calculated Oxford Hip Score For Patient Name: