INSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to do your usual activities. Answer every question by ticking the appropriate box. If you are unsure about how to answer a question, please give the best answer you can.
Symptoms These questions should be answered thinking of your knee symptoms during the last week.
1. What is the highest level of activity that you can perform without significant knee pain?
2. During the past 4 weeks, or since injury, how often have you had pain?
0 - Never10 - Constant000
3. If you have pain, how severe is it?
0 - Never10 - Constant000
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 that 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?
How does your knee affect your ability to:
9. Go up stairs
10. Go down stairs
11. Kneel on the front of your knee
12. Squat
13. Sit with your knee bent
14. Rise from a chair
15. Run straight ahead
16. Jump and land on involved leg
17. Stop and start quickly
Function, and activity of daily living The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your knee.
18. 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 knee injury: (not scored, for purpose of benchmarking)
0 - Cannot Perform ADL10 - No limitation of ADL000
19. Current function of your knee:
0 - Cannot Perform ADL10 - No limitation of ADL000