Hip Wellness Assessment
Welcome to the Hip Wellness Assessment! This tool provides a quick and comprehensive evaluation of
your hip health. By assessing key areas of functionality, strength, and mobility, you'll gain
valuable insights to help maintain and improve your hip wellness. Start now to take the first step
towards optimal hip health!
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Patient Identifier:
Date completed:
Section 1: Pain
I have no pain at the moment
Slight, occasional, no compromise in activity
Mild pain, no effect on average activities
Moderate pain, tolerable but makes concessions to pain.
Marked pain, serious limitation of activities
Totally disabled, crippled, pain in bed, bedridden
Section 2: Support
None
Cane/Walking stick for long walks
Cane/Walking stick most of the time
One crutch
Two Canes/Walking sticks
Two crutches or not able to walk
Section 3: Distance walked
Unlimited
Six blocks (30 minutes)
Two or three blocks (10 - 15 minutes)
Indoors only
Bed and chair only
Totally disabled, crippled
Section 4: Walking
Pain does not prevent me from walking any
distance
Pain prevents me from walking more than 1
mile
Pain prevents me from walking more than 1/2
mile
Pain prevents me from walking more than 1/4
mile
I can walk only with crutches or a cane
I am in bed most of the time and have to crawl
to the toilet
Section 5: Sitting
I can sit in any chair as long as I like
I can only sit in my favorite chair as long
as I like
Pain prevents me from sitting more than 1
hour
Pain prevents me from sitting more than 1/2
hour
Pain prevents me from sitting more than 10
minutes
I avoid sitting because it increases pain
immediately
Section 6: Standing
I can stand as I like
I can only stand as long
as I like
Pain prevents me from Standing more than 1
hour
Pain prevents me from Standing more than 1/2
hour
Pain prevents me from Standing more than 10
minutes
I avoid Standing because it increases pain
immediately
Section 7: Sleeping
I can sleep as I like
I can only sleep as long
as I like
Pain prevents me from Sleeping more than 1
hour
Pain prevents me from Sleeping more than 1/2
hour
Pain prevents me from Sleeping more than 10
minutes
I avoid Sleeping because it increases pain
immediately
Section 8: Stairs
Normally without using a railing
Normally using a railing
In any manner
Unable to do stairs
Pain prevents me from doing
I avoid because it increases pain
immediately
Section 9: Social Life
I can involve as I like
I can only involve as long
as I like
Pain prevents me from involving more peoples
Pain prevents me from involving more peoples comfort
Pain prevents me from involving more peoples Severe
I avoid involving because it increases pain
immediately
Section 10: Travelling
I can travel as I like
I can only travel as long
as I like
Pain prevents me from Travelling more than 1
hour
Pain prevents me from Travelling more than 2
day
Pain prevents me from Travelling more than 10
days
I avoid Travelling because it increases pain
immediately
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