Hip Survey 2020 - PREOP


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

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

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.


Mercy Hospital participates in the Joint Commission Disease Specific Certification program. As a participating organization, Mercy tracks specific data related to the care of patients having knee replacement, hip replacement and spine surgery. This data is used to improve program quality and patient care experience. Personal patient information is protected.