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UCLA Activity Score

UCLA Activity Score - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Questionnaires

Hip ID:
Study Hip: � Left � Right
Examination Date (MM/DD/YY): / /
Subject Initials: |____|____|____|
UCLA Activity Score
Medical Record Number:

Check one box that best describes current activity level.
� 1: Wholly Inactive, dependent on others, and can not leave residence

� 2: Mostly Inactive or restricted to minimum activities of daily living

� 3: Sometimes participates in mild activities, such as walking, limited housework and limited shopping

� 4: Regularly Participates in mild activities

� 5: Sometimes participates in moderate activities such as swimming or could do unlimited housework or shopping

� 6: Regularly participates in moderate activities

� 7: Regularly participates in active events such as bicycling

� 8: Regularly participates in active events, such as golf or bowling

� 9: Sometimes participates in impact sports such as jogging, tennis, skiing, acrobatics, ballet, heavy labor or backpacking

� 10: Regularly participates in impact sports

Interval: ______________