KOOS-12

KOOS-12

Knee Injury and Osteoarthritis Outcome Score
Name*

First NameLast Name
Email*
example@example.com
Today's Date*

MonthDayYear
Date
If you are completing this form regarding a different date, enter it here (Month, Day, Year)

MonthDayYear
Date
Please indicate which knee this survey is about:*

LeftRight
VAS: Overall, how bad is your pain (0=no pain, 100 =maximum imaginable pain)*

Pain*

Rows	Never	Monthly	Weekly	Daily	Always
1. How often do you experience knee pain?

Pain - What amount of knee pain have you experienced in the LAST WEEK during the following activities?*

Rows	None	Mild	Moderate	Severe	Extreme
2. Walking on flat surface
3. Going up or down stairs
4. Sitting or lying

Function, daily living - Thinking about the LAST WEEK: The following questions concern your physical function. By this we mean your ability to move around and to look after yourself.*

Rows	None	Mild	Moderate	Severe	Extreme
5. Rising from sitting
6. Standing
7. Getting in/out of a car
8. Twisting / pivoting on your knee

Quality of Life*

Rows	Never	Monthly	Weekly	Daily	Always
9. How often are you aware of your knee problem?

Quality of Life*

Rows	Not at all	Mild	Moderate	Severe	Extreme
10. Have much have you modified your life style to avoid activities potentially damaging to your knee?
11. How much are you troubled with a lack of confidence in your knee?
12. In general, how much difficulty do you have with your knee?

Pain Subtotal: (0-100; 100 is no pain at all)
Function and daily living subtotal: (0-100; 100 is perfect function)
Quality of life subtotal (QOL): (0-100; 100 is perfect QOL)
Overall KOOS-12 Score (0-100; 100 is a perfect knee)
Should be Empty: