WOMAC Survey

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. Who is your Physiotherapist?

Mandi Hayes

Jennifer Duke

Anthony Giorgianni

Jeanine Stott

Beata Sadowska

Heather Clegg

Chris Cosby

I cannot remember

Instructions: In Sections 2, 3, and 4, questions will be asked about your hip or knee pain. Please select the most appropriate response. If you are unsure about how to answer a question, please give the best answer you can.

Question Title

* 3. Think about the pain you felt in your hip/knee during the last 48 hours. How much pain do you have?

	0 None	1 Mild	2 Moderate	3 Severe	4 Extreme
Walking on a flat surface	Walking on a flat surface 0 None	Walking on a flat surface 1 Mild	Walking on a flat surface 2 Moderate	Walking on a flat surface 3 Severe	Walking on a flat surface 4 Extreme
Going up and down stairs	Going up and down stairs 0 None	Going up and down stairs 1 Mild	Going up and down stairs 2 Moderate	Going up and down stairs 3 Severe	Going up and down stairs 4 Extreme
At night while in bed, pain disturbs your sleep	At night while in bed, pain disturbs your sleep 0 None	At night while in bed, pain disturbs your sleep 1 Mild	At night while in bed, pain disturbs your sleep 2 Moderate	At night while in bed, pain disturbs your sleep 3 Severe	At night while in bed, pain disturbs your sleep 4 Extreme
Sitting or lying	Sitting or lying 0 None	Sitting or lying 1 Mild	Sitting or lying 2 Moderate	Sitting or lying 3 Severe	Sitting or lying 4 Extreme
Standing upright	Standing upright 0 None	Standing upright 1 Mild	Standing upright 2 Moderate	Standing upright 3 Severe	Standing upright 4 Extreme

Question Title

* 4. Think about the stiffness (not pain) you have in your hip/knee during the last 48 hours. Stiffness is a sensation of decreased
ease in moving your joint.

	0 None	1 Mild	2 Moderate	3 Severe	4 Extreme
How severe is your stiffness after first awakening in the morning?	How severe is your stiffness after first awakening in the morning? 0 None	How severe is your stiffness after first awakening in the morning? 1 Mild	How severe is your stiffness after first awakening in the morning? 2 Moderate	How severe is your stiffness after first awakening in the morning? 3 Severe	How severe is your stiffness after first awakening in the morning? 4 Extreme
How severe is your stiffness after sitting, lying, or resting in the day?	How severe is your stiffness after sitting, lying, or resting in the day? 0 None	How severe is your stiffness after sitting, lying, or resting in the day? 1 Mild	How severe is your stiffness after sitting, lying, or resting in the day? 2 Moderate	How severe is your stiffness after sitting, lying, or resting in the day? 3 Severe	How severe is your stiffness after sitting, lying, or resting in the day? 4 Extreme

Question Title

* 5. Think about the difficulty you had in doing the following daily physical activities due to your hip/knee during the last 48 hours.
By this we mean your ability to move around and look after yourself. What degree of difficulty do you have?

	0 None	1 Mild	2 Moderate	3 Severe	4 Extreme
Descending stairs	Descending stairs 0 None	Descending stairs 1 Mild	Descending stairs 2 Moderate	Descending stairs 3 Severe	Descending stairs 4 Extreme
Ascending stairs	Ascending stairs 0 None	Ascending stairs 1 Mild	Ascending stairs 2 Moderate	Ascending stairs 3 Severe	Ascending stairs 4 Extreme
Rising from sitting	Rising from sitting 0 None	Rising from sitting 1 Mild	Rising from sitting 2 Moderate	Rising from sitting 3 Severe	Rising from sitting 4 Extreme
Standing	Standing 0 None	Standing 1 Mild	Standing 2 Moderate	Standing 3 Severe	Standing 4 Extreme
Bending to the floor	Bending to the floor 0 None	Bending to the floor 1 Mild	Bending to the floor 2 Moderate	Bending to the floor 3 Severe	Bending to the floor 4 Extreme
Walking on flat surfaces	Walking on flat surfaces 0 None	Walking on flat surfaces 1 Mild	Walking on flat surfaces 2 Moderate	Walking on flat surfaces 3 Severe	Walking on flat surfaces 4 Extreme
Getting in and out of a car, or on or off a bus	Getting in and out of a car, or on or off a bus 0 None	Getting in and out of a car, or on or off a bus 1 Mild	Getting in and out of a car, or on or off a bus 2 Moderate	Getting in and out of a car, or on or off a bus 3 Severe	Getting in and out of a car, or on or off a bus 4 Extreme
Going shopping	Going shopping 0 None	Going shopping 1 Mild	Going shopping 2 Moderate	Going shopping 3 Severe	Going shopping 4 Extreme
Putting on your socks or stockings	Putting on your socks or stockings 0 None	Putting on your socks or stockings 1 Mild	Putting on your socks or stockings 2 Moderate	Putting on your socks or stockings 3 Severe	Putting on your socks or stockings 4 Extreme
Rising from the bed	Rising from the bed 0 None	Rising from the bed 1 Mild	Rising from the bed 2 Moderate	Rising from the bed 3 Severe	Rising from the bed 4 Extreme
Taking off your socks or stockings	Taking off your socks or stockings 0 None	Taking off your socks or stockings 1 Mild	Taking off your socks or stockings 2 Moderate	Taking off your socks or stockings 3 Severe	Taking off your socks or stockings 4 Extreme
Lying in bed	Lying in bed 0 None	Lying in bed 1 Mild	Lying in bed 2 Moderate	Lying in bed 3 Severe	Lying in bed 4 Extreme
Getting in or out of the bath	Getting in or out of the bath 0 None	Getting in or out of the bath 1 Mild	Getting in or out of the bath 2 Moderate	Getting in or out of the bath 3 Severe	Getting in or out of the bath 4 Extreme
Sitting	Sitting 0 None	Sitting 1 Mild	Sitting 2 Moderate	Sitting 3 Severe	Sitting 4 Extreme
Getting on or off the toilet	Getting on or off the toilet 0 None	Getting on or off the toilet 1 Mild	Getting on or off the toilet 2 Moderate	Getting on or off the toilet 3 Severe	Getting on or off the toilet 4 Extreme
Performance heavy domestic duties	Performance heavy domestic duties 0 None	Performance heavy domestic duties 1 Mild	Performance heavy domestic duties 2 Moderate	Performance heavy domestic duties 3 Severe	Performance heavy domestic duties 4 Extreme
Performing light domestic duties	Performing light domestic duties 0 None	Performing light domestic duties 1 Mild	Performing light domestic duties 2 Moderate	Performing light domestic duties 3 Severe	Performing light domestic duties 4 Extreme

Question Title

* 6. SCORING - for office use only

PAIN SCORE = add up all scores __/20 = _ STIFFNESS SCORE = add up all scores/8 = PHYSICAL FUNCTION SCORE = add up all scores /68 = __

This questionnaire is taken from: McConnell S, Kolopack P, Davis AM. The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC): a review of its utility and measurement properties. Arthritis Care & Research: Official Journal of the American College of Rheumatology. 2001 Oct;45(5):453-61.

Question Title

* 1. Please type your name. Surname, First Name

Question Title

* 2. Who is your Physiotherapist?

Question Title

* 3. Think about the pain you felt in your hip/knee during the last 48 hours. How much pain do you have?

Question Title

* 4. Think about the stiffness (not pain) you have in your hip/knee during the last 48 hours. Stiffness is a sensation of decreasedease in moving your joint.

Question Title

* 5. Think about the difficulty you had in doing the following daily physical activities due to your hip/knee during the last 48 hours.By this we mean your ability to move around and look after yourself. What degree of difficulty do you have?

Question Title

* 6. SCORING - for office use onlyPAIN SCORE = add up all scores ______/20 = _______ STIFFNESS SCORE = add up all scores______/8 = ______ PHYSICAL FUNCTION SCORE = add up all scores ______/68 = ______

* 4. Think about the stiffness (not pain) you have in your hip/knee during the last 48 hours. Stiffness is a sensation of decreased
ease in moving your joint.

* 5. Think about the difficulty you had in doing the following daily physical activities due to your hip/knee during the last 48 hours.
By this we mean your ability to move around and look after yourself. What degree of difficulty do you have?

* 6. SCORING - for office use only

PAIN SCORE = add up all scores __/20 = _ STIFFNESS SCORE = add up all scores/8 = PHYSICAL FUNCTION SCORE = add up all scores /68 = __