33

INTERNATIONAL Hip Outcome Tool IHOT

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 answer each question with respect to the current status, function, circumstances
and beliefs related to your hip.

• Consider the last month.

• The questions are formatted so that you can indicate the severity of the problem by
circling a number below the question.

Please note:

Please circle the number which most closely represents your situation.

• If you circle a number on the far left, it means that you feel you are significantly
impaired. For example:

0------1-------2------3------4------5------6------7------8------9------10
Significantly Impaired No Problems At All

• If you circle a number on the far right, it means that you do not think that you have any
problems with your hip.
For example:
 0------1-------2------3------4------5------6------7------8------9------10
Significantly Impaired No Problems At All

If a number is circled in the middle of the line, this indicates that you are moderately disabled,
or in other words, between the extremes of ‘significantly impaired’ and ‘no problems at all’. It is
important to circle a number at the appropriate end of the line if the extreme descriptions
accurately reflect your situation.

If the question asks about something that you do not experience, please mark the option:

I do not do this action in my activities, where this is appropriate.

The following questions ask about symptoms that you may experience in
your hip and about the function of your hip with respect to daily activities.
Please think about how you have felt most of the time over the past month
and answer accordingly.

1. How often does your hip/groin ache?

0------1-------2------3------4------5------6------7------8------9------10
Constantly Never

2. How stiff is your hip as a result of sitting/resting during the day?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Stiff Not Stiff At All

3. How difficult is it for you to walk long distances?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Difficult Not Difficult At All
4. How much pain do you have in your hip while sitting?

0------1-------2------3------4------5------6------7------8------9------10
Extreme Pain No Pain At All

5. How much trouble do you have standing on your feet for long
period of time?

0------1-------2------3------4------5------6------7------8------9------10
Severe Trouble No Trouble At All

6. How difficult is it for you to get up and down off the floor/ground?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Difficult Not Difficult At All

7. How difficult is it for you to walk on uneven surfaces?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Difficult Not Difficult At All
8. How difficult is it for you to lie on your affected hip side?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Difficult Not Difficult At All

9. How much trouble do you have with stepping over obstacles?

0------1-------2------3------4------5------6------7------8------9------10
Severe Trouble No Trouble At All

10. How much trouble do you have climbing up/downstairs?

0------1-------2------3------4------5------6------7------8------9------10
Severe Trouble No Trouble At All

11. How much trouble do you have with rising from a sitting position?

0------1-------2------3------4------5------6------7------8------9------10
Severe Trouble No Trouble At All
12. How much discomfort do you have with taking long strides?

0------1-------2------3------4------5------6------7------8------9------10
Extreme Discomfort No Discomfort At All

13. How much difficulty do you have with getting into and/or out of a
car?
0 ------1-------2------3------4------5------6------7------8------9------10
Extreme Difficulty No Difficulty At All

14. How much trouble do you have with grinding, catching, or clicking
in your hip?
0------1-------2------3------4------5------6------7------8------9------10
Severe Trouble No Trouble At All

15. How much difficulty do you have with putting on/taking off socks,
stockings, or shoes?
0------1-------2------3------4------5------6------7------8------9------10
Extreme Difficulty No Difficulty At All
14. Overall, how much pain do you have in your hip/groin?

0------1-------2------3------4------5------6------7------8------9------10
Extreme Pain No Pain At All

______________________________________________________________________________

II: SPORTS AND RECREATIONAL ACTIVITIES

The following questions ask about your hip when you participate in sports
and recreational activities. Please think about how you have felt most of
the time over the past month and answer accordingly.

17. How concerned are you about your ability to maintain your desired
fitness level?
0------1-------2------3------4------5------6------7------8------9------10
Extremely Concerned Not Concerned At All

18. How much pain do you experience in your hip after activity?

0------1-------2------3------4------5------6------7------8------9------10
Extreme Pain No Pain At All
19. How concerned are you that the pain in your hip will increase if you
participate in sports or recreational activities?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Concerned Not Concerned At All

20. How much was your quality of life deteriorated because you cannot
participate in sport/recreational activities?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Deteriorated Not Deteriorated At All

21. How concerned are you about cutting/changing directions during

I do not do this action in my activities.

0------1-------2------3------4------5------6------7------8------9------10
Extremely Concerned Not Concerned At All

22. How much has your performance level decreased in your sport or
recreational activities?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Decreased Not Decreased At All
III: JOB RELATED CONCERNS

The following questions relate to your hip with respect to your work or
occupational activities. Please think about how you have felt most of the
time over the past month and answer accordingly.

I am retired (please skip section)

I do not work for reasons other than my hip condition (please skip section)

23. How much trouble do you have pushing, pulling, lifting, or carrying
heavy objects at work?

I do not do these actions in my work.

0------1-------2------3------4------5------6------7------8------9------10
Severe Trouble No Trouble At All

24. How much trouble do you have with crouching/squatting?

0------1-------2------3------4------5------6------7------8------9------10
Severe Trouble No Trouble At All
25. How concerned are you that your job will make your hip worse?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Concerned Not Concerned At All

26. How much trouble do you have at work because of reduced hip
mobility?

0------1-------2------3------4------5------6------7------8------9------10
Extreme Difficulty No Difficulty At All

______________________________________________________________________________

IV: SOCIAL, EMOTIONAL AND LIFESTYLE CONCERNS

The following questions ask about social, emotional and lifestyle concerns
that you may feel with respect to your hip problem. Please think about
how you have felt most of the time over the past month and answer
accordingly.

27. How frustrated are you because of your hip problem?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Frustrated Not Frustrated At All
28. How much trouble do you have with sexual activity because of your
hip?

This is not relevant to me.

0------1-------2------3------4------5------6------7------8------9------10
Severe Trouble No Trouble At All

29. How much of a distraction is your hip problem?

0------1-------2------3------4------5------6------7------8------9------10
Extreme Distraction No Distraction At All

30. How difficult is it for you to release tension and stress because of
your hip problem?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Difficult Not Difficult At All

31. How discouraged are you because of your hip problem?

0------1-------2------3------4------5------6------7------8------9------10
Extremely Discouraged Not Discouraged At All
32. How concerned are you about picking up or carrying children
because of your hip?

I do not do this action in my activities.

0------1-------2------3------4------5------6------7------8------9------10
Extremely Concerned Not Concerned At All

33. How much of the time are you aware of the disability in your hip?

0------1-------2------3------4------5------6------7------8------9------10
Constantly Aware Not Aware At All

QUESTIONNAIRE COMPLETE!

THANK YOU!