Modified Harris Hip Score
Name
*
First Name
Middle Name
Last Name
Date of Birth
*
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Month
-
Day
Year
Date
Date of Appointment
*
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Month
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Day
Year
Date
Time of Appointment
*
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Hour
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50
Minutes
AM
PM
AM/PM Option
Please mark one of the following for each topic.
Which best describes your pain?
*
Which best describes your limp?
*
Which best describes the support you use?
*
Which best describes the distance you can walk?
*
How do you handle stairs?
*
How do you handle putting on socks & shoes?
*
How do you handle sitting?
*
How do you use public transportation?
*
Submit
Should be Empty: