First name
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Last name
*
Email address
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Date of Birth
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How would you describe the pain you usually have from your hip?
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None
Very mild
Mild
Moderate
Severe
Have you had any trouble with washing and drying yourself (all over) because of your hip?
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No trouble at all
Very little trouble
Moderate trouble
Extreme difficulty
Impossible to do
Have you had any trouble getting in and out of a car or using public transport because of your hip? (whichever you would tend to use)
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No trouble at all
Very little trouble
Moderate trouble
Extreme difficulty
Impossible to do
Have you been able to put on a pair of socks, stockings or tights?
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Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible
Could you do the household shopping on your own?
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Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible
For how long have you been able to walk before pain from your hip becomes severe? (with or without a stick)
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No pain/more than 30 minutes
16 to 30 minutes
5 to 15 minutes
Around the house only
Not at all - pain severe when walking
Have you been able to climb a flight of stairs?
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Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible
After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your hip?
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Not at all painful
Slightly painful
Moderately painful
Very painful
Unbearable
Have you had any sudden, severe pain - 'shooting', 'stabbing' or 'spasms' - from the affected hip?
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No days
Only 1 or 2 days
Some days
Most days
Every day
How much has pain from your hip interfered with your usual work (including housework)?
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Not at all
A little bit
Moderately
Greatly
Totally
Have you been troubled by pain from your hip in bed at night?
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No nights
Only 1 or 2 nights
Some nights
Most nights
Every night
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