1

Do you have pain in the groin, thigh or buttock?

• Yes
• Sometimes
• NO

2

Do you have difficulty putting on your shoes and socks?

• Yes
• Sometimes
• No

3

Does pain relief medication not work any more?

• Yes
• Sometimes
• No

4

Does anti-inflammatory medication no longer work?

• Yes
• Sometimes
• No

5

Have you been diagnosed with Hip Arthritis?

• Yes
• No

6

Does your hip grind or click?

• Yes
• No