Pain

Tell us how much pain you are experiencing and how often.

Pain When Walking on a Flat Surface*
Pain Going Up or Down Stairs*
Pain When Sitting or Lying*
How Often Do You Experience Hip Pain?*

Functions of Daily Living

For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your hip:

Standing*
Rising From Sitting*
Getting In and Out of a Vehicle*
Twisting or Pivoting on the Leg with the Problem Hip*

Quality of Life

Tell us how much pain you are experiencing and how often.

How often are you aware of your hip problem?*
Have you modified your lifestyle to avoid activities that make your hip worse?*
Do you feel troubled with lack of confidence in your hip?*
In general, how much difficulty do you have with your hip?*
Have you ever been a patient at OrthoNebraska?*
What is Your Gender?*
Name*
Submit your answers, and we'll email you the results. We'll also follow up with next steps and contact information to help you get closer to returning to the activities you love. OrthoNebraska pain assessments are not intended or implied to be a substitute for professional medical advice, diagnosis or treatment. For a full diagnosis, schedule an appointment with one of our specialists, visit an OrthoNebraska Orthopedic Urgent Care or our emergency room. You understand that by completing this form, you are consenting to receive phone and email communications from OrthoNebraska, but you can opt-out at any time.*
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