PASC Hip Scores (SANE/HOOS)
Please enter the date *
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Last Name *
Your answer
First Name *
Your answer
Date of Birth *
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Treating Doctor *
Which hip was treated *
If both hips were treated please fill out a separate survey for each hip
Hip SANE-F Score *
Enter a number for the current functional level of your hip. 100% is normal function, 0% is completely disabled
Your answer
Hip SANE-I Score
Enter a number for the % improvement of your hip compared to before treatment. 100% is completely better, 0% is no improvement
Your answer
The HOOS Hip Survey should take 10 minutes to fill out and has 5 Subsections (Symptoms, Pain, Function, Sports, Lifestyle)
Your answer
The following 5 questions refer to hip symptoms you have had in the past week.
Your answer
Do you feel grinding, hear clicking or any other type of noise from your hip? (S1)
Difficulty spreading legs wide apart? (S2)
Difficulty striding out when walking? (S3)
How severe is your hip joint stiffness after waking up in the morning? (S4)
How severe is your hip stiffness after sitting, lying or resting later in the day? (S5)
HOOS Hip Symptom Section Scoring (For PASC Staff Use Only)
None=0; Mild=1; Moderate=2; Severe=3; Always/extreme=4 100- (TOTAL x 100)/20 = SCORE
Your answer
HOOS Symptom Score (For PASC Staff Use Only)
Your answer
The next 10 questions refer to any hip pain you have had in the last week
Your answer
How often is your hip painful? (P1)
How much hip pain have you had in the last week straightening your hip fully? (P2)
How much hip pain have you had in the last week bending your hip fully? (P3)
How much hip pain have you had in the last week walking on flat surfaces? (P4)
How much hip pain have you had in the last week going up and down stairs? (P5)
How much hip pain have you had in the last week at night while in bed? (P6)
How much hip pain have you had in the last week sitting or lying? (P7)
How much hip pain have you had in the last week standing upright? (P8)
How much hip pain have you had in the last week walking on a hard surface (asphalt, concrete, etc.)? (P9)
How much hip pain have you had in the last week walking on an uneven surface? (P10)
HOOS Hip Pain Scoring Section (for PASC Staff Only)
none=0; mild=1; moderate=2; severe=3; always/extreme=4 100 - (TOTAL x 100)/40 = SCORE
Your answer
HOOS Pain Score (for PASC Staff Only)
Your answer
The next 17 questions refer to your physical function in the last week.
Your answer
How much difficulty have you had descending stairs? (A1)
How much difficulty have you had ascending stairs? (A2)
How much difficulty have you had rising from sitting? (A3)
How much difficulty have you had standing? (A4)
How much difficulty have you had bending to the floor or picking up an object? (A5)
How much difficulty have you had walking on a flat surface? (A6)
How much difficulty have you had getting in and out of a car? (A7)
How much difficulty have you had going shopping ? (A8)
How much difficulty have you had putting on socks or stockings? (A9)
How much difficulty have you had rising from bed? (A10)
How much difficulty have you had taking off socks or stockings? (A11)
How much difficulty have you had lying in bed? (A12)
How much difficulty have you had getting in and out of the bath? (A13)
How much difficulty have you had sitting? (A14)
How much difficulty have you had getting on an off the toilet? (A15)
How much difficulty have you had with heavy domestic duties (moving heavy boxes, scrubbing floors, etc.)? (A16)
How much difficulty have you had with light domestic duties (cooking, dusting, etc.)? (A17)
HOOS Hip ADL Scoring Section (For PASC Staff)
none=0; mild=1; moderate=2; severe=3; always/extreme=4 100- (TOTAL x 100)/68 = SCORE
Your answer
HOOS ADL Score (For PASC Staff)
Your answer
The next 4 questions refer to your physical function in sports and recreational activities in last week.
Your answer
How much difficulty have you had with squatting? (SP1)
How much difficulty have you had with running? (SP2)
How much difficulty have you had with twisting or pivoting? (SP3)
How much difficulty have you had walking on an uneven surface? (SP4)
HOOS Hip Sports/ Rec Scoring Section (For PASC Staff)
none=0; mild=1; moderate=2; severe=3; always/extreme=4 100- (TOTAL x 100)/16 = SCORE
Your answer
HOOS Sports/ Rec Score (For PASC Staff)
Your answer
The next 4 questions refer to your quality of life in last week.
Your answer
How often are you aware of your hip problem? (Q1)
Have you modified your lifestyle to avoid potentially damaging activities to your hip? (Q2)
How much are you troubled with lack of confidence in your hip? (Q3)
In general how much difficulty do you have with your hip? (Q4)
HOOS Hip QOL Scoring Section (For PASC Staff)
none=0; mild=1; moderate=2; severe=3; always/extreme=4 100- (TOTAL x 100)/16 = SCORE
Your answer
HOOS QOL Score (For PASC Staff)
Your answer
HOOS Overall Score (For PASC Staff)
Add 5 sections and divide by 5. 100 is no disability, 0 is complete disability
Your answer
Thank you for completing the HOOS Hip Survey!
Your answer
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