Date of completion

WOMAC Score

Patient's name (or ref
Clinician's name (or ref)
Patient's d.o.b
 

INSTRUCTIONS: This survey asks for your view about your hip. This information will help us keep track of how you feel about your hip and how well you are able to do your usual activities.

Answer every question by ticking the appropriate box. If you are unsure about how to answer a question, please give the best answer you can.
 

Symptoms - These questions should be answered thinking of your hip symptoms during the last week.

1. Do you feel grinding, hear clicking or any other type of noise from you hip?

Never Rarely Sometimes Often Always
 

2. Difficulties spreading legs wide apart

None Mild Moderate Severe Extreme

3. Difficulties to stride out when walking

None Mild Moderate Severe Extreme

Stiffness - The following questions concern the amount of joint stiffness you have experienced during the last week in your hip. Stiffness is a sensation of restriction or slowness in the ease with which you move your hip joint.

4. How severe is your hip joint stiffness after first wakening in the morning?

None Mild Moderate Severe Extreme

7. How severe is your hip stiffness after sitting, lying or resting later in the day?

None Mild Moderate Severe Extreme
 

Pain

1. How often is your hip painful?

Never Monthly Weekly Daily Always
 

What amount of hip pain have you experienced the last week during the following activities?

2. Straightening your hip fully

None Mild Moderate Severe Extreme

3. Bending your hip fully

None Mild Moderate Severe Extreme
 

4. Walking on flat surface

None Mild Moderate Severe Extreme
 

5. Going up or down stairs

None Mild Moderate Severe Extreme
 

6. At night while in bed

None Mild Moderate Severe Extreme
 

7. Sitting or lying

None Mild Moderate Severe Extreme
 

8. Standing upright

None Mild Moderate Severe Extreme
 

9. Walking on a hard surface (asphalt, concrete, etc)

None Mild Moderate Severe Extreme
 

10. Walking on an uneven surface

None Mild Moderate Severe Extreme
 

Function, daily living - The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your hip.

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. Standing

None Mild Moderate Severe Extreme
 

5. Bending to floor/pick up an object

None Mild Moderate Severe Extreme
 

6. Walking on flat surface

None Mild Moderate Severe Extreme
 

7. Getting in/out of car

None Mild Moderate Severe Extreme
 

8. Going shopping

None Mild Moderate Severe Extreme
 

9. Putting on socks/stockings

None Mild Moderate Severe Extreme
 

10. Rising from bed

None Mild Moderate Severe Extreme
 

11. Taking off socks/stockings

None Mild Moderate Severe Extreme
 

12. Lying in bed (turning over, maintaining hip position)

None Mild Moderate Severe Extreme
 

13. Getting in/out of bath

None Mild Moderate Severe Extreme
 

14. Sitting

None Mild Moderate Severe Extreme
 

15. Getting on/off toilet

None Mild Moderate Severe Extreme
 

16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)

None Mild Moderate Severe Extreme
 

17. Light domestic duties (cooking, dusting, etc)

None Mild Moderate Severe Extreme

Thank you very much for completing all the questions in this questionnaire.

To save this data please print or

 
WOMAC score is

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Lethem J, Slade PD, Troup JDG, Bendey G. Outline of a fear avoidance model of exaggerated pain perceptions, Behav Res Ther. 1983;21:401-408.

Williamson E. Fear Avoidance Behavior Questionnaire. Austrailian Journal of Physiotherapy. 2006; 52: 149.

Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eck H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62: 36, 272.