Self-assessment surveys - Pages

1 / 21

Grade symptoms at the highest activity level at which you think you could function without significant symptoms, even if you are not actually performing activities at this level.

Please choose one of the options

Choose answers for the last week.

Please choose one of the options

3 / 21

What is the highest level of activity that you can perform without significant knee pain?

Please choose one of the options

Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running or jogging

Light activities like walking, housework or yard work

Unable to perform any of the above activities due to knee pain

4 / 21

During the past 4 weeks, or since your injury, how often have you had pain?

Please choose one of the options

0 Never

1

2

3

4

5

6

7

8

9

10 Constant

5 / 21

If you have pain, how severe is it?

Please choose one of the options

0 No pain

1

2

3

4

5

6

7

8

9

10

6 / 21

During the past 4 weeks, or since your injury, how stiff or swollen was your knee?

Please choose one of the options

Not at all

Mildly

Moderately

Very

Extremely

7 / 21

What is the highest level of activity you can perform without significant swelling in your knee?

Please choose one of the options

Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running or jogging

Light activities like walking, housework or yard work

Unable to perform any of the above activities due to knee swelling

8 / 21

During the past 4 weeks, or since your injury, did your knee lock or catch?

Please choose one of the options

Yes

No

9 / 21

What is the highest level of activity you can perform without significant giving way in your knee?

Please choose one of the options

Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running or jogging

Light activities like walking, housework or yard work

Unable to perform any of the above activities due to knee

10 / 21

How does your knee affect your ability to go up stairs?

Please choose one of the options

Not difficult at all

Minimally difficult

Moderately Difficult

Extremely difficult

Unable to do

11 / 21

How does your knee affect your ability to go down stairs?

Please choose one of the options

Not difficult at all

Minimally difficult

Moderately Difficult

Extremely difficult

Unable to do

12 / 21

How does your knee affect your ability to kneel on the front of your knee?

Please choose one of the options

Not difficult at all

Minimally difficult

Moderately Difficult

Extremely difficult

Unable to do

13 / 21

How does your knee affect your ability to squat?

Please choose one of the options

Not difficult at all

Minimally difficult

Moderately Difficult

Extremely difficult

Unable to do

14 / 21

How does your knee affect your ability to sit with your knee bent?

Please choose one of the options

Not difficult at all

Minimally difficult

Moderately Difficult

Extremely difficult

Unable to do

15 / 21

How does your knee affect your ability to rise from a chair?

Please choose one of the options

Not difficult at all

Minimally difficult

Moderately Difficult

Extremely difficult

Unable to do

16 / 21

How does your knee affect your ability to run straight ahead?

Please choose one of the options

Not difficult at all

Minimally difficult

Moderately Difficult

Extremely difficult

Unable to do

17 / 21

How does your knee affect your ability to jump and land on your involved leg?

Please choose one of the options

Not difficult at all

Minimally difficult

Moderately Difficult

Extremely difficult

Unable to do

18 / 21

How does your knee affect your ability to stop and start quickly?

Please choose one of the options

Not difficult at all

Minimally difficult

Moderately Difficult

Extremely difficult

Unable to do

19 / 21

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?

Please choose one of the options

20 / 21

Function prior to your knee injury:

Please choose one of the options

0 Couldn't perform daily activities

1

2

3

4

5

6

7

8

9

10 No limitation in daily activities

21 / 21

Current function of your knee:

Please choose one of the options

0 Cannot perform daily activities

1

2

3

4

5

6

7

8

9

10 No limitation in daily activities