Pre-Surgery Knee Questionnaire Name *Email Address *1.How would you describe the pain you usually have in your knee?NoneVery MildMildModerateSevere2. Have you had any trouble washing and drying yourself (all over) because of your knee?No trouble at allVery little troubleModerate troubleExtreme difficulty Impossible to do3. Have you had any trouble getting in and out of the car or using public transport because of your knee? (With or without a stick)No trouble at allVery little troubleModerate troubleExtreme difficultyImpossible to do4. For how long are you able to walk before the pain in your knee becomes severe? (With or without a stick)No pain > 60 min16 - 60 minutes5 - 15 minutesAround the house onlyNot at all - severe on walking5. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your knee?Not at all painfulSlightly painfulModerately painVery painfulUnbearable6. Have you been limping when walking, because of your knee?Rarely / neverSometimes or just at firstOften, not just at firstMost of the timeAll of the time7. Could you kneel down and get up again afterwards?Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficultyNo, impossible8. Are you troubled by pain in your knee at night in bed?Not at allOnly one or two nightsSome nightsMost nightsEvery night 9. How much has pain from your knee interfered with your usual work? (including housework)Not at allA little bitModeratelyGreatly Totally10. Have you felt that your knee might suddenly �give away� or let you down? Rarely / NeverSometimes or just at first Often, not at firstMost of the timeAll the time11. Could you do household shopping on your own?Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficultyNo, impossible12. Could you walk down a flight of stairs?Yes, easilyWith little difficultyWith moderate difficultyWith extreme difficultyNo, impossiblePre-Surgery Knee ScoreSend Message
