Survey before hip surgery

Are you a:


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.

I acknowledge it is in my best interest, as a patient of Northern Light Mercy Hospital, to watch the following video as a way to prepare for my upcoming surgery. If I have any questions after watching the video or do not understand parts of the video, I agree to contact Mercy Hospital at 207-553-6541, to help optimize my experience.

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.