WOMAC Osteoarthritis Index

Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Date*

MonthDayYear
Date
Email
example@example.com
The following questions concern the amount of pain you are currently experiencing in your knees. For each situation, please enter the amount of pain you have experienced in the past 48 hours.
1. Walking on a flat surface*

No PainMildModerateSevereWorst Pain
2. Going up or down stairs*

No PainMildModerateSevereWorst Pain
3. At night while in bed*

No PainMildModerateSevereWorst Pain
4. Sitting or lying down*

No PainMildModerateSevereWorst Pain
5. Standing upright*

No PainMildModerateSevereWorst Pain
6. Level of pain in RIGHT knee*

No PainMildModerateSevereWorst Pain
7. Level of pain in LEFT knee*

No PainMildModerateSevereWorst Pain
8. How severe is your stiffness after first awakening in the morning?*

No PainMildModerateSevereWorst Pain
9. How severe is your stiffness after sitting, lying or resting later in the day?*

No PainMildModerateSevereWorst Pain
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 48 hours, in your knees.
1. Descending (going down) stairs*

No PainMildModerateSevereWorst Pain
2. Ascending (going up) stairs*

No PainMildModerateSevereWorst Pain
3. Rising from sitting*

No PainMildModerateSevereWorst Pain
4. Standing*

No PainMildModerateSevereWorst Pain
5. Bending to floor*

No PainMildModerateSevereWorst Pain
6. Walking on a flat surface*

No PainMildModerateSevereWorst Pain
7. Getting in/out of car*

No PainMildModerateSevereWorst Pain
8. Going shopping*

No PainMildModerateSevereWorst Pain
9. Putting on socks/stockings*

No PainMildModerateSevereWorst Pain
10. Rising from bed*

No PainMildModerateSevereWorst Pain
11. Taking off socks/stockings*

No PainMildModerateSevereWorst Pain
12. Lying in bed*

No PainMildModerateSevereWorst Pain
13. Getting in/out of bath*

No PainMildModerateSevereWorst Pain
14. Sitting*

No PainMildModerateSevereWorst Pain
15. Getting on/off toilet*

No PainMildModerateSevereWorst Pain
16. Heavy domestic duties (mowing the lawn, lifting heavy grocery bags)*

No PainMildModerateSevereWorst Pain
17. Light domestic duties (such as tidying a room, dusting, cooking)*

No PainMildModerateSevereWorst Pain
Score
Provider Signature

Clear
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