KOOS-12
Knee Injury and Osteoarthritis Outcome Score
Name
*
First Name
Last Name
Email
*
example@example.com
Today's Date
*
-
Month
-
Day
Year
Date
If you are completing this form regarding a different date, enter it here (Month, Day, Year)
-
Month
-
Day
Year
Date
Please indicate which knee this survey is about:
*
Left
Right
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)
Submit
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