1. During the past 4 weeks … How would you describe the pain you usually have from your hip?

None (4)

Very mild (3)

Mild (2)

Moderate (1)

Severe (0)

2. During the past 4 weeks … Have you had any trouble with washing and drying yourself (all over) because of your hip?

No trouble at all (4)

Very little trouble (3)

Moderate trouble (2)

Extreme difficulty (1)

Impossible to do (0)

3. During the past 4 weeks … Have you had any trouble getting in and out of a car or using public transportation because of your hip? (whichever you tend to use)

No trouble at all (4)

Very little trouble (3)

Moderate trouble (2)

Extreme difficulty (1)

Impossible to do (0)

4. During the past 4 weeks … Have you been able to put on a pair of socks, stockings or tights?

Yes, easily (4)

With little difficulty (3)

With moderate difficulty (2)

With extreme difficulty (1)

No, impossible (0)

5. During the past 4 weeks … Could you do the household shopping on your own?

Yes, easily (4)

With little difficulty (3)

With moderate difficulty (2)

With extreme difficulty (1)

No, impossible (0)

6. During the past 4 weeks … For how long have you been able to walk before pain from your hip becomes severe (with or without a stick)?

No pain/ for ≥30 min (4)

16–30 min (3)

5–15 min (2)

Around the house only (1)

Not at all (0)

7. During the past 4 weeks … Have you been able to climb a flight of stairs?

Yes, easily (4)

With little difficulty (3)

With moderate difficulty (2)

With extreme difficulty (1)

No, impossible (0)

8. During the past 4 weeks … 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 (4)

Slightly painful (3)

Moderately painful (2)

Very painful (1)

Unbearable (0)

9. During the past 4 weeks … Have you been limping when walking because of your hip?

Rarely/never (4)

Sometimes or just at first (3)

Often, not just at first (2)

Most of the time (1)

All of the time (0)

10. During the past 4 weeks … Have you had any sudden, severe pain - ‘shooting’, ‘stabbing’ or ‘spasms’ - from the affected hip?

No days (4)

1 or 2 days (3)

Some days (2)

Most days (1)

Every day (0)

11. During the past 4 weeks … How much has pain from your hip interfered with your usual work (including housework)?

Not at all (4)

A little bit (3)

Moderately (2)

Greatly (1)

Totally (0)

12. During the past 4 weeks … Have you been troubled by pain from your hip in bed at night?

No nights (4)

1 or 2 nights (3)

Some nights (2)

Most nights (1)

Every night (0)