Knee
Instructions: Below are common complaints which people frequently have with their knee problems.Please check the statement which best describes your condition.
LIMP:
I have no limp when I walk.(5)
I have a slight or periodical limp when I walk(3).
I have a severe and constant limp when I walk(0).
USING CANE OR CRUTCHES
I do not use a cane or crutches. (5)
I use a cane or crutches with some ____ weight-bearing(2)
Putting weight on my hurt leg is impossible. (0)
LOCKING SENSATION IN THE KNEE
I have no locking and no catching sensations in my knee. (15)
I have catching sensation but no locking sensation in my knee. (10)
My knee locks occasionally. (6)
My knee locks frequently. (2)
My knee feels locked at this moment. (0)
GIVING WAY SENSATION FROM THE KNEE
My knee never gives way. (25)
My knee rarely gives way, only during athletics or other vigorous activities. (20)
My knee frequently gives way during athletics orother vigorous activities, in turn I am unable to participate in these activities. (15)
My knee occasionally gives way during daily activities. (10)
My knee often gives way during daily activities. (5)
My knee gives way every step I take. (0)
PAIN:
I have no pain in my knee. (25)
I have intermittent or slight pain in my knee during vigorous activities. (20)
I have marked pain in my knee during vigorous activities. (15)
I have marked pain in my knee during or after walking more than 1 mile. (10)
I have marked pain in my knee during or after walking less than 1 mile. (5)
I have constant pain in my knee. (0)
SWELLING
I have no swelling in my knee. (10)
)I have swelling in my knee only after vigorous activities. (6)
I have swelling in my knee after ordinary activities. (2)
I have swelling constantly in my knee. (0)
Climbing Stairs
I have no problems climbing stairs. (10)
I have slight problems climbing stairs. (6)
I can climb stairs only one at a time. (2)
Climbing stairs is impossible for me. (0)
SQUATTING
I have no problems squatting. (5)
I have slight problems squatting. (4)
I can not squat beyond a 90 degree bend in my knee. (2)
My knee gives way every step I take. (0)
Squatting is impossible because of my knee(0)
TOTAL_____/100
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INSTRUCTIONS: Please indicate the amount of pain you have had in your knee(s) the past 24 hours. The scale ranges from “no pain at all” to the “worst possible pain”.
Pain
Rows
0
1
2d
3
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5
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7
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10
Pain
First Name and Age
First Name
Age
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Signature
Submit
Should be Empty: