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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.

S1. Do you feel grinding, hear clicking or any other type of noise from you hip?

Never Rarely Sometimes Often Always
 

S2. Difficulties spreading legs wide apart
None Mild Moderate Severe Extreme

S3. 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.

S4. How severe is your hip joint stiffness after first wakening in the morning?

None Mild Moderate Severe Extreme

S7. How severe is your hip stiffness after sitting, lying or resting later in the day?

None Mild Moderate Severe Extreme
 

Pain

P1. 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?

P2. Straightening your hip fully

None Mild Moderate Severe Extreme

P3. Bending your hip fully

None Mild Moderate Severe Extreme
 

P4. Walking on flat surface

None Mild Moderate Severe Extreme
 

P5. Going up or down stairs

None Mild Moderate Severe Extreme
 

P6. At night while in bed

None Mild Moderate Severe Extreme
 

P7. Sitting or lying

None Mild Moderate Severe Extreme
 

P8. Standing upright

None Mild Moderate Severe Extreme
 

P9. Walking on a hard surface (asphalt, concrete, etc)

None Mild Moderate Severe Extreme
 

P10. 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.

Al. Descending stairs

None Mild Moderate Severe Extreme
 

A2. Ascending stairs

None Mild Moderate Severe Extreme
 

A3. Rising from sitting

None Mild Moderate Severe Extreme
 

A4. Standing

None Mild Moderate Severe Extreme
 

A5. Bending to floor/pick up an object

None Mild Moderate Severe Extreme
 

A6. Walking on flat surface

None Mild Moderate Severe Extreme
 

A7. Getting in/out of car

None Mild Moderate Severe Extreme
 

A8. Going shopping

None Mild Moderate Severe Extreme
 

A9. Putting on socks/stockings

None Mild Moderate Severe Extreme
 

A10. Rising from bed

None Mild Moderate Severe Extreme
 

A11. Taking off socks/stockings

None Mild Moderate Severe Extreme
 

A12. Lying in bed (turning over, maintaining hip position)

None Mild Moderate Severe Extreme
 

A13. Getting in/out of bath

None Mild Moderate Severe Extreme
 

A14. Sitting

None Mild Moderate Severe Extreme
 

A15. Getting on/off toilet

None Mild Moderate Severe Extreme
 

A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)

None Mild Moderate Severe Extreme
 

A17. 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

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The WOMAC score is

Reference for Score: Klassbo M, Larsson E, Mannevik E. Hip disability and osteoarthritis outcome score. An extension of the Western Ontario and McMaster Universities Osteoarthritis Index. Scand J Rheumatol. 2003;32(1):46-51. Link