OBJECTIVES: Clinical Outcomes Assessments (COAs) frequently include questions to assess patients’ ability to perform specific activities. Some activities may not be applicable in the target country, necessitating adaptation during translation. When requiring adaptation, a tendency exists to substitute an equally recognizable, but non-equivalent, activity. Consideration of movements and exertion, as well as cultural appropriateness, is imperative. Failure to do so can impede data pooling across languages in multinational trials. METHODS: Languages observed were Eastern European, Indian, Middle Eastern, Asian, and Southeast Asian, all of which presented difficulties in adapting “Western” activities. The activities analyzed appeared in actual patient questionnaires that underwent linguistic validation. Alternatives were recommended by linguists and cognitive debriefing subjects. RESULTS: In Arabic for Egypt, “bocce” was deemed inapplicable. “Billiards” was suggested as an appropriate alternative as both require standing and light exertion. “Bocce” also posed difficulties for Indian languages. The initial alternative was “cricket,” however, cricket requires higher exertion and running. A suitable alternative was “playing marbles,” as the Indian version requires standing, light movement, and no running. Questionnaires also may assess one’s ability to complete personal hygiene tasks, such as “getting in and out of a bathtub.” In Indian languages, cognitive debriefing subjects did not understand “bathtub,” as a majority of the target sample do not have “bathtubs” at home. A suitable alternative was “to sit on and get up from a small stool in order to take a bath with a tumbler.” This activity replicated both the source movement and exertion with a culturally appropriate activity. CONCLUSIONS: Adaptation of Western activities in COAs requires consideration of the movement and exertion involved in the source, as well as maintaining cultural appropriateness and familiarity to the respondent. This is essential when creating a localized questionnaire that will yield sound data across languages.