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  • Research Questionnaire

    ACL reconstruction or repair

    Thank you for filling out this questionnaire which Dr Pai uses to ensure you are recovering well from your surgery. To keep track of your progress, you will be asked to complete this again at your future follow-up appointments. This questionnaire should take no longer than 10 minutes.


    All the questions pertain to the side you have had surgery on. If you have any questions, please don't hesitate to ask our practice team at admin@vishalpai.com or call us on 03 8657 0595.

  • Date of Birth*
     - -
    2 digit day, 2 digit month, 4 digit year
  • At what time point are you filling this form?*

  • Satisfaction Rating

  • Taking account of all the activity you have during your daily life, your level of pain and also your activity limitations and participations restrictions, do you consider the current state of your knee satisfactory?*

  • EQ-5D-5L

  • Under each heading, please tick the ONE box that best describes your health TODAY:

  • MOBILITY*
  • SELF-CARE*
  • USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities)*
  • PAIN / DISCOMFORT*
  • ANXIETY / DEPRESSION*

  • We would like to know how good or bad your health is TODAY.

    This scale is numbered from 0 to 100.

    100 means the best health you can imagine.

    0 means the worst health you can imagine.

  • Please adjust the scale to indicate how your health is TODAY.*

  • IKDC-SKF

  • SYMPTOMS

    *Grade symptoms at the highest activity level at which you think you could function without significant symptoms, even if you are not actually performing activities at this level.

  • 1. What is the highest level of activity that you can perform without significant knee pain?*
  • 4. During the past 4 weeks, or since your injury, how stiff or swollen was your knee?*
  • 5. What is the highest level of activity you can perform without significant swelling in your knee?*
  • 6. During the past 4 weeks, or since your injury, did your knee lock or catch?*
  • 7. What is the highest level of activity you can perform without significant giving way in your knee?*

  • SPORTS ACTIVITIES

  • 8. What is the highest level of activity you can participate in on a regular basis?*
  • 9. How does your knee affect your ability to:*
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  • FUNCTION

  • 10. How would you rate the function of your knee on a scale of 0 to 10 with 10 being normal, excellent function and 0 being the inability to perform any of your usual daily activities which may include sports?

  • Function prior to your knee injury:
  • Current function of your knee:*

  • Marx Activity Scale

  • Please indicate how often you performed each activity in your healthiest and most active state, in the past year.*
    Rows
  • Should be Empty: