Instructions
This survey asks for your view about your hip. This information will help us keep track of how you feel about your hip and how well you are able to do your usual activities.

Answer every question by ticking the appropriate box, only one box for each question. If you are unsure about how to answer a question, please give the best answer you can.

This survey and its results do not replace any actuall diagnosis by a trained and licensed professional.

Pain

What amount of hip pain have you experienced the last week during the following activities?
1. Going Up Stairs
2. Walking on an Uneven Surface

Function, Daily Living

The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your hip.
3. Rising From Sitting
4. Bending to Floor / Pick up an Object
5. Lying in Bed (Turning Over, Maintaining Hip Position
6. Sitting
Have you been diagnosed with hip dysplasia?

Your Age

Please indicate your age.