Traverse City, MI Hip Pain Assessment

Section 1 of 3

1. Which hip is causing you problems?

Left Right Both

2. How would you describe your hip pain?

3. How long have you had this pain?

4. On a scale of 1-5, how much worse has your hip pain gotten recently?

5. Have you gone through physical therapy for treatment of your hip pain?

Yes No

6. Have you received injections into your hip joint as part of your treatment for hip pain?

Yes No I do not know

7. If you have received hip injections, when did they start?

8. Have you been told that you have (or are concerned that you have) a sensitivity/allergy to certain types of metal?

Yes No I do not know

Section 2 of 3

9. 9. How long can you walk, with or without a cane or walking device, before hip pain becomes an issue?

10. Does hip pain cause you to limp?

11. In a month, how many nights does hip pain affect your sleep?

12. How much does your hip pain limit your daily activities?

13. How often do you feel like your hip is unstable or may fail to support you?

14. Can you perform activities such as shopping and housekeeping on your own?

Section 3 of 3

15. Please list your top 4 responses to the following question:
After surgery, I want a hip replacement that:

Most important:

Next most important:

Third most important:

Fourth most important:

16. What do you miss most because of hip pain?

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Brent Wiersema, DO Hip Pain Assessment

Section 1 of 3

Section 2 of 3

Section 3 of 3

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POLAR3^◊ Total Hip Solution for Hip Replacement

XLPE Material in Hip Replacement Implants

Hip Arthritis

Brent Wiersema, DO Hip Pain Assessment

Section 1 of 3

Section 2 of 3

Section 3 of 3

You're almost done!

Print out your results

POLAR3◊ Total Hip Solution for Hip Replacement

XLPE Material in Hip Replacement Implants

Hip Arthritis

POLAR3^◊ Total Hip Solution for Hip Replacement