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Activity Report

Today’s Date
 

Last Name

First Name

Date of Birth
 

Enter the number of weeks after surgery

What percentage of your daily activities have you been able to resume since the surgery?

     
     
     
   

Which of the following best describes your current ability to move up and down stairs?

Today, is your range of motion progressing as you expected?

Are you able to stand up from a seated position without pushing off with your arms?

 
 

Today, what percent of your quads function have you attained according to your physical therapist?

     
     
     
   

Today, how straight is your knee?

   
   
 

Today, how many degrees can you bend your knee?

     
     
     
     
   

Thank you for completing this questionnaire!

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