OBJECTIVES: When developing a new PRO for use in multinational studies it is recommended that a translatability assurance step is conducted before finalization and its subsequent translation and linguistic validation. A review of translatability and subsequent adaptation can reduce the chances of encountering difficulties related to concepts, idiomatic expressions, response scales, or syntax once translation has started. This step helps identify potential issues and develop solutions that side-step potential problems in the later translation process. The aim of this study was to assess the nature of issues that translatability highlights. METHODS: Translatability is assessed by native speakers representing several language groups (e.g. Europe, Africa, Asia, and Latin America). The linguists are asked to identify possible grammatical, lexical and cultural issues. Their recommendations are compiled and discussed with the developer of the measure, which is then adapted in accordance with these findings. The results of translatability checks were reviewed to find common issues that the process illuminates.  RESULTS: Changes made to a PRO as a direct result of a translatability step can be varied but all work towards clarity of concepts and expression. Common changes are: 1) Complex sentences are segmented for clarity; 2) Ambiguity is removed; 3) Constructs common in English but not in other languages are changed; 4) Colloquialisms are simplified; 5) Elaborations are added to clarify concepts; and 6) Unnecessary noun repetition is removed. CONCLUSIONS: The translatability assurance step can increase cross-cultural equivalence between original and translated documents, and tackle potential translation difficulties uniformly before translation begins. It is recommended as a step in all PRO development projects.