iHot 12 hip score

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    Patient's name: E-mail:
    Date of Birth: NHS Number:
    Date: Side: LeftRight

    INSTRUCTIONS

    These questions ask about the problems you may be experiencing in your hip, how these problems affect your life, and the emotions you may feel because of these problems.

    Please indicate the severity by selecting a number between 1 and 10. 1 being the most severe and 10 being the least significant.

    Please let your answers describe the typical situation in the last month

    (TIP If you don't do an activity, imagine how your hip would feel if you had to try it.)

    Q1. Overall, how much pain do you have in your hip/groin?
    (1 = Extreme pain, 10 = No pain at all)
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    Q2. How difficult is it for you to get up and down off the floor/ground?
    (1 = Extreme difficult, 10 = Not difficult at all)
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    Q3. How difficult is it for you to walk long distances?
    (1 = Extreme difficult, 10 = Not difficult at all)
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    Q4. How much trouble do you have grinding, cathing or clicking in your hip? (1 = Severe trouble, 10 = No trouble at all)
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    Q5. How much trouble do you have pushing, pulling, lifting or carrying heavy objects? (1 = Severe trouble, 10 = No trouble at all)
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    Q6. How concerned are you about cutting/changing directions during your sport or recreational activities?
    (1 = Extremely concerned, 10 = Not concerned at all)
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    Q7. How much pain do you experience in your hip after activity?
    (1 = Extremely pain, 10 = No pain at all)
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    Q8. How concerned are you about picking up or carrying children because of your hip?
    (1 = Extremely concerned, 10 = Not concerned at all)
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    Q9. much trouble do you have with sexual activity because of your hip?
    (1 = Severe trouble, 10 = No trouble at all)
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    Q10. How much of time are you aware of the disability in your hip?
    (1 = Constantly aware, 10 = Not aware at all)
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    Q11. How concerned are you about your ability to maintain your desired fitness level??
    (1 = Extremely concerned, 10 = Not concerned at all)
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    Q12. How much of a distraction is your hip problem?
    (1 = Extremely distraction, 10 = Nodistraction at all)
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