During the past four weeks … | (Tick one box for each question) | ||||
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1. How would you describe the pain you usually have from your hip? | None | Very mild | Mild | Moderate | Severe |
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2. Have you had any trouble with washing and drying yourself (all over) because of your hip? | No trouble at all | Very little trouble | Moderate trouble | Extreme difficulty | Impossible to do |
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3. Have you had any trouble getting in and out of a car or using public transport because of your hip? | No trouble at all | Very little trouble | Moderate trouble | Extreme difficulty | Impossible to do |
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4. Have you been able to put on a pair of socks, stockings, or tights? | Yes, easily | With little difficulty | With moderate difficulty | With extreme difficulty | No, impossible |
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5. Could you do the household shopping on your own? | Yes, easily | With little difficulty | With moderate difficulty | With extreme difficulty | No, impossible |
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6. For how long have you been able to walk before pain from your hip becomes severe? (With or without a walking aid) | No pain/more than 30 min | 16 to 30 min | 5 to 15 min | Around the house only | Not at all—pain severe on walking |
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7. Have you been able to climb a flight of stairs? | Yes, easily | With little difficulty | With moderate difficulty | With extreme difficulty | No, impossible |
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8. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip? | Not at all painful | Slightly painful | Moderately painful | Very painful | Unbearable |
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9. Have you been limping when walking because of your hip? | Rarely/never | Sometimes or just at first | Often, not just at first | Most of the time | All of the time |
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10. Have you had any sudden, severe pain—'shooting', 'stabbing' or 'spasms' from your affected hip? | No days | Only 1 or 2 days | Some days | Most days | Every day |
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11. How much has the pain from your hip interfered with your usual work, including housework? | Not at all | A little bit | Moderately | Greatly | Totally |
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12. Have you been troubled by pain from your hip in bed at night? | No nights | Only 1 or 2 nights | Some nights | Most nights | Every night |
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