The following questionnaire is designed to determine the symptoms and limitations that you experience because of your knee while you perform your usual daily activities. Please answer each question by checking the one statement that best describes you over the last 1 to 2 days. For a given question, more than one of the statements may describe you, but please mark only the statement which best describes you during your usual daily activities.
Knee Outcome Survey Activities of Daily Living Scale
1. Pain
I do not have the symptom (5) I have the symptom but it doesn't affect my activity (4) The symptom affects my activity slightly (3) The symptom affects my activity moderately (2) The symptom affects my activity severely (1) The symptom prevents me from all daily activity (0)
2. Stiffness
I do not have the symptom (5) I have the symptom but it doesn't affect my activity (4) The symptom affects my activity slightly (3) The symptom affects my activity moderately (2) The symptom affects my activity severely (1) The symptom prevents me from all daily activity (0)
3. Swelling
I do not have the symptom (5) I have the symptom but it doesn't affect my activity (4) The symptom affects my activity slightly (3) The symptom affects my activity moderately (2) The symptom affects my activity severely (1) The symptom prevents me from all daily activity (0)
4. Giving way, buckling, or shifting of the knee
I do not have the symptom (5) I have the symptom but it doesn't affect my activity (4) The symptom affects my activity slightly (3) The symptom affects my activity moderately (2) The symptom affects my activity severely (1) The symptom prevents me from all daily activity (0)
5. Weakness
I do not have the symptom (5) I have the symptom but it doesn't affect my activity (4) The symptom affects my activity slightly (3) The symptom affects my activity moderately (2) The symptom affects my activity severely (1) The symptom prevents me from all daily activity (0)
6. Limping
I do not have the symptom (5) I have the symptom but it doesn't affect my activity (4) The symptom affects my activity slightly (3) The symptom affects my activity moderately (2) The symptom affects my activity severely (1) The symptom prevents me from all daily activity (0)
Functional Limitations With Activities of Daily Living: How does your knee affect your ability to…
7. Walk
Acitivity is not difficult (5) Activity is minimally difficult (4) Activity is somewhat difficult (3) Activity is fairly difficult (2) Activity is very difficult (1) I am unable to do the activity (0)
8. Go up stairs
Acitivity is not difficult (5) Activity is minimally difficult (4) Activity is somewhat difficult (3) Activity is fairly difficult (2) Activity is very difficult (1) I am unable to do the activity (0)
9. Go down stairs
Acitivity is not difficult (5) Activity is minimally difficult (4) Activity is somewhat difficult (3) Activity is fairly difficult (2) Activity is very difficult (1) I am unable to do the activity (0)
10. Stand
Acitivity is not difficult (5) Activity is minimally difficult (4) Activity is somewhat difficult (3) Activity is fairly difficult (2) Activity is very difficult (1) I am unable to do the activity (0)
11. Kneel on the front of your knee
Acitivity is not difficult (5) Activity is minimally difficult (4) Activity is somewhat difficult (3) Activity is fairly difficult (2) Activity is very difficult (1) I am unable to do the activity (0)
12. Squat
Acitivity is not difficult (5) Activity is minimally difficult (4) Activity is somewhat difficult (3) Activity is fairly difficult (2) Activity is very difficult (1) I am unable to do the activity (0)
13. Sit with your knee bent
Acitivity is not difficult (5) Activity is minimally difficult (4) Activity is somewhat difficult (3) Activity is fairly difficult (2) Activity is very difficult (1) I am unable to do the activity (0)
14. Rise from a chair
Acitivity is not difficult (5) Activity is minimally difficult (4) Activity is somewhat difficult (3) Activity is fairly difficult (2) Activity is very difficult (1) I am unable to do the activity (0)
Knee Outcome Survey Sports Activities Scale
15. Pain
Never have (5) Have, but does not affect my sports activity (4) Affects sports activity slightly (3) Affects sports activity moderately (2) Affects sports activity severely (1) Prevents me from all sports activity (0)
16. Grinding or grating
Never have (5) Have, but does not affect my sports activity (4) Affects sports activity slightly (3) Affects sports activity moderately (2) Affects sports activity severely (1) Prevents me from all sports activity (0)
17. Stiffness
Never have (5) Have, but does not affect my sports activity (4) Affects sports activity slightly (3) Affects sports activity moderately (2) Affects sports activity severely (1) Prevents me from all sports activity (0)
18. Swelling
Never have (5) Have, but does not affect my sports activity (4) Affects sports activity slightly (3) Affects sports activity moderately (2) Affects sports activity severely (1) Prevents me from all sports activity (0)
19. Slipping or partial giving way of knee
Never have (5) Have, but does not affect my sports activity (4) Affects sports activity slightly (3) Affects sports activity moderately (2) Affects sports activity severely (1) Prevents me from all sports activity (0)
20. Buckling or full giving way of knee
Never have (5) Have, but does not affect my sports activity (4) Affects sports activity slightly (3) Affects sports activity moderately (2) Affects sports activity severely (1) Prevents me from all sports activity (0)
21. Weakness
Never have (5) Have, but does not affect my sports activity (4) Affects sports activity slightly (3) Affects sports activity moderately (2) Affects sports activity severely (1) Prevents me from all sports activity (0)
Functional Limitations With Sports Activities: How does your knee affect your ability to
22. Run straight ahead
Not difficult at all (5) Minimally difficult (4) Somewhat difficult (3) Fairly difficult (2) Very difficult (1) Unable to do (0)
23. Jump and land on your involved leg
Not difficult at all (5) Minimally difficult (4) Somewhat difficult (3) Fairly difficult (2) Very difficult (1) Unable to do (0)
24. Stop and start quickly
Not difficult at all (5) Minimally difficult (4) Somewhat difficult (3) Fairly difficult (2) Very difficult (1) Unable to do (0)
25. Cut and pivot on your involved leg
Not difficult at all (5) Minimally difficult (4) Somewhat difficult (3) Fairly difficult (2) Very difficult (1) Unable to do (0)