Hip Survey | Broward Health

We are pleased that you chose our award-winning Joint Replacement Center for your total hip/knee surgery. In order to assess the care rendered to our patients and the outcomes of their surgery, we ask that you complete the following survey prior to your procedure.

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 checking the appropriate box. Please check only one box for each question. If you are unsure about how to answer a question, please give the best answer you can.

Patient Name

Telephone

Date of SurgeryMM-DD-YYYY

Surgeon's Name

Date of BirthMM-DD-YYYY

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

1) Going up or down stairs:

2) Walking on an uneven surface:

Function, daily living: The following questions concern your physical function. By this we mean your ability to move around and to look after yourself.

1) Rising from sitting:

2) Bending to floor/pick up an object:

3) Lying in bed (turning over, maintaining hip position):

4) Sitting:

Thank you for your participation in this survey. Your efforts assist in the service we provide and the outcomes of our patients. If you would like to know more on how this survey helps to improve patient care, feel free to contact the Rehabilitation Services Department at 954-786-5102

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