Hips/Pelvis Pain Assessment

Is the pain on one side or both?

The pain is on one side, either the left or right hip/pelvis.

The pain is on both sides of my hips/pelvis.

The pain is in the centre of my pelvis.

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Does the pain radiate to the lower back or legs?

Yes, the pain radiates to my lower back or down my legs, particularly the thigh or knee.

Yes, the pain radiates down my leg, sometimes reaching my foot.

No, the pain does not radiate to my lower back or legs.

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Do you experience stiffness when getting up from a seated position?

Yes, I experience stiffness in my hips or pelvis when I get up, and it takes a moment to ease up.

Yes, I feel tightness or discomfort when transitioning from sitting to standing.

No, I do not experience any stiffness when getting up from a seated position.

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Is the pain sharp, aching, or throbbing?

The pain is sharp, especially with movement or certain positions.

The pain is aching, constant, and dull, especially when I’m sitting or at rest.

The pain is throbbing, like a pulsing sensation that comes and goes.

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Have you recently started a new physical activity?

Yes, I have recently started a new activity, such as running, cycling, or weightlifting.

Yes, I began doing a new exercise routine or sport that involves more strain on my hips/pelvis.

No, I have not started any new physical activities recently.

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How long have you been experiencing this pain?

Less than a week

1-4 weeks

Over a month

Other

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How would you rate your pain on a scale of 1-10?

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Have you taken any medications or treatments for this pain?

Yes

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Is this pain the first time you’ve experienced it, or have you had similar pain before?

Yes, this is the first time I’m experiencing this type of pain.

No, I’ve had this type of pain before, but it went away after a while.

No, I’ve had similar pain before, and it has been recurring.

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Have you ever been involved in a road traffic accident (car, bike, or pedestrian)?

Yes, I’ve been in a road traffic accident before and sustained injuries.

Yes, but I did not experience significant injuries at the time.

No, I’ve never been in a road traffic accident.

Please select an option before proceeding.

Have you ever had any fractures or dislocations in your body, particularly around the affected area?

Yes, I have had a fracture or dislocation in the area experiencing pain.

Yes, I’ve had a fracture or dislocation in another area of my body.

No, I’ve never had any fractures or dislocations.

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Have you undergone any surgeries in the past, especially related to the area experiencing pain?

Yes, I’ve had surgery in the affected area (e.g., hip, shoulder, back).

Yes, I’ve had surgeries elsewhere in my body but not in the affected area.

No, I have never had any surgeries.

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Do you have any other medical conditions that might be related to the pain, such as arthritis, diabetes, or autoimmune disorders?

Yes, I have a medical condition (e.g., arthritis, diabetes, fibromyalgia) that may be related to the pain.

No, I don’t have any known medical conditions related to the pain.

I’m not sure, but I’ve been diagnosed with other health issues.

Please select an option before proceeding.

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Last Name

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Age

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Hips/Pelvis Pain Assessment

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