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KOOS Knee Survey (Knee Osteoarthritis Outcome Survey)

Today’s Date
 

Last Name

First Name

Date of Birth
 

Date of Surgery
 

What Time Period Are You Reporting?

Knee Symptoms and Stiffness during the last week

S1. Do you have swelling in your knee?

S2. Do you feel grinding, hear clicking or any other type of noise when your knee moves?

S3. Does your knee catch or hang up when moving?

S4. Can you straighten your knee fully?

S5. Can you bend your knee fully?

S6. How severe is your knee joint stiffness after first wakening in the morning?

S7. How severe is your knee stiffness after sitting, lying or resting later in the day?

Pain

P1. How often do you experience knee pain?

Pain in the knee during the last week when doing the following activities:

P2. Twisting/pivoting on your knee

P3. Straightening knee fully

P4. Bending knee fully

P5. Walking on flat surface

P6. Going up or down stairs

P7. At night while in bed

P8. Sitting or lying

P9. Standing upright

Function and Daily Living (Physical Function)

How difficult is each of the following activites during the last week due to your knee

Al. Descending stairs

A2. Ascending stairs

A3. Rising from sitting

A4. Standing

A5. Bending to floor/pick up an object

A6. Walking on flat surface

A7. Getting in/out of car

A8. Going shopping

A9. Putting on socks/stockings

A10. Rising from bed

A11. Taking off socks/stockings

A12. Lying in bed (turning over, maintaining knee position)

A13. Getting in/out of bath

A14. Sitting

A15. Getting on/off toilet

A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)

A17. Light domestic duties (cooking, dusting, etc)

Function, Sports and Recreational Activities (physical function when active on a higher level) Think about the degree of difficulty when doing the following activities during the last week due to your knee?

SP1. Squatting

SP2. Running

SP3. Jumping

SP4. Twisting/pivoting on your injured knee

SP5. Kneeling

Quality of Life.

Q1. How often are you aware of your knee problem?

Q2. Have you modified your life style to avoid potentially damaging activities to your knee?

Q3. How much are you troubled with lack of confidence in your knee?

Q4. In general, how much difficulty do you have with your knee?

Thank you for completing this questionnaire!

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