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Patient's Name

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Patient's Date of Birth

Date

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Today's Date

Date

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Please select all sides in which you have had a knee replacement.

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 as indicated by marking the appropriate box. Mark ONLY ONE box for EACH question. 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.

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S1. Do you have swelling in your knee?

  Never Rarely Sometimes Often Always
Right:
Left:

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

  Never Rarely Sometimes Often Always
Right:
Left:

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

  Never Rarely Sometimes Often Always
Right:
Left:

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S4. Can you straighten your knee fully?

  Never Rarely Sometimes Often Always
Right:
Left:

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S5. Can you bend your knee fully?

  Never Rarely Sometimes Often Always
Right:
Left:
STIFFNESS: The following questions concern the amount of joint stiffness you have experienced during the last week in your knee. Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint.

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

  None Mild Moderate Severe Extreme
Right:
Left:

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

  None Mild Moderate Severe Extreme
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Left:
PAIN:

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P1. How often do you experience pain?

  Never Monthly Weekly Daily Always
Right:
Left:
What amount of knee pain have you experienced in the last week during the following activities?

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P2. Twisting/pivoting on your knee?

  None Mild Moderate Severe Extreme
Right:
Left:
 
25% of survey complete.

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