Please answer the following 12 multiple choice questions about your knee symptoms over the last 4 weeks...

How would you describe the pain you usually have from your knee?

None

Very mild

Mild

Moderate

Severe

Have you had any trouble with washing and drying yourself (all over) because of your knee?

No trouble

Very little trouble

Moderate trouble

Exteme difficulty

Impossible to do

Have you had any trouble getting in and out of a car or using public transport because of your knee? (whichever you tend to use)

No trouble

Very little trouble

Moderate trouble

Extreme difficulty

Impossible to do

For how long have you been able to walk before the pain from your knee becomes severe (with or without a stick)

No pain / more than 30 minutes

16 to 30 minutes

5 to 15 minutes

Around the house only

Not at all / pain severe when walking

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 painful

Slightly painful

Moderately painful

Very painful

Unbearable

Have you been limping when walking, because of your knee?

Rarely / never

Sometimes, or just at first

Often, not just at first

Most of the time

All of the time

Could you kneel down and get up again afterwards?

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

Have you been troubled by pain from your knee in bed at night?

No nights

Only 1 or 2 nights

Some nights

Most nights

Every night

How much has pain from your knee interfered with your usual work (including housework)?

Not at all

A little bit

Moderately

Greatly

Totally

Have you felt that your knee might suddenly “give way” or let you down?

Rarely / never

Sometimes, or just at first

Often, not just at first

Most of the time

All of the time

Could you do the household shopping on your own?

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No impossible

Could you walk down a flight of stairs?

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

First Name *

Last Name *

Email *

Phone *

Thank you...now for your results

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