By answering the following questions, you will be able to indicate the status of your hip and/or knee: 1. Does your hip or knee give you problems when you walk? No, it does not affect my walking Yes, some problems, but I still can get to where I'm going Yes, so much that I am stuck inside my home 2. Does your hip or knee affect the way you take care of yourself? No, I have no problems washing or dressing myself Yes, some problems, but I can still wash and dress myself Yes, so much that I am unable to wash or dress myself 3. Does your hip or knee affect your daily activities (i.e. work, chores, family, leisure, etc.)? No, I have no problems performing my daily activities Yes, some problems, but I can still perform my daily activities Yes, so much that I am unable to wash or dress myself 4. How much hip or knee pain do you have? None Moderate Extreme 5. Does your hip or knee pain make you feel anxious or depressed? No, I do not feel anxious or depressed Yes, the pain makes me feel moderately anxious and depressed Yes, the pain makes me feel extremely anxious and depressed

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