Geniculate Embolization Outcome Questionaire

Background

The questionnaire is a modified Oxford Knee Score (OKS). The OKS was developed in 1998 and validated to measure pain and function after total knee replacement.

This assessment will be used to assess your knee before and after treatment with Geniculate Embolization. The procedure has been discussed with you at length with additional written information provided.

Please fill the form out to the best of your ability prior to your intervention, with follow-up assessments at 3, 6 & 12 months.

If any queries arise or if you can not fill this form out online please contact the office on 9386 6200 or via admin@ponoshvascular.com.au.

This questionnaire should take about three minutes to complete. We thank you for you co-operation and assistance.

Question Title

1. What is your name?

Question Title

2. Which knee is planned for treatment or has been treated?

Right

Left

Both

Question Title

3. Is this questionnaire being completed ....

Before your geniculate embolization

Three (3) months after your geniculate embolization

Six (6) months after your geniculate embolization

Twelve (12) months after your geniculate embolization

Question Title

4. What is today's date?

Date / Time

Date

Question Title

5. How would you describe the pain you usually have in your knee? (Required.)

None

Very mild

Mild

Moderate

Severe

Question Title

6. Have you had any issues washing and drying yourself (all over) because of your knee? (Required.)

No trouble

Very little trouble

Moderate trouble

Extreme difficulty

Impossible to do

Question Title

7. Have you had any issues getting in and out of a car or public transport because of your knee (with or without a stick)? (Required.)

No trouble

Very little trouble

Moderate trouble

Extreme difficulty

Impossible to do

Question Title

8. For how long are you able to walk walk before your knee pain becomes severe (with or without a stick)? (Required.)

No pain at all - > 60 minutes

16 - 60 minutes

5 - 15 minutes

Around the house

Not at all - severe pain on walking

Question Title

9. After a meal (sat at table), how painful has it been to stand up from a chair because of your knee? (Required.)

Not at all

Slightly painful

Moderately painful

Very painful

Unbearable

Question Title

10. Have you been limping when walking because of your knee? (Required.)

Rarely/never

Sometimes or just at first

Often, not just at first

Most of the time

All of the tine

Question Title

11. Could you kneel down and get up again afterwards? (Required.)

Yes easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, not at all

Question Title

12. Are you troubled by pain in your knee at night in bed? (Required.)

Not at all

Only one or two nights

Some nights

Most nights

Every night

Question Title

13. How much has pain from your knee interferes with your usual work (including housework)? (Required.)

Not at all

A little bit

Moderately

Greatly

Totally

Question Title

14. Have you felt your knee might suddenly give way or let you down? (Required.)

Rarely/Never

Sometimes or just at first

Often, not just at first

Most of the time

All of the time

Question Title

15. Could you do household shopping on your own? (Required.)

Yes easily

With a little difficulty

With moderate difficulty

With extreme difficulty

No impossible

Question Title

16. Could you walk down a flight of stairs? (Required.)

Yes easily

With a little difficulty

With moderate difficulty

With extreme difficulty

No impossible

Geniculate Embolization Outcome Questionaire

Background

Question Title

* 1. What is your name?

Question Title

* 2. Which knee is planned for treatment or has been treated?

Question Title

* 3. Is this questionnaire being completed ....

Question Title

* 4. What is today's date?

Question Title

* 5. How would you describe the pain you usually have in your knee? (Required.)

Question Title

* 6. Have you had any issues washing and drying yourself (all over) because of your knee? (Required.)

Question Title

* 7. Have you had any issues getting in and out of a car or public transport because of your knee (with or without a stick)? (Required.)

Question Title

* 8. For how long are you able to walk walk before your knee pain becomes severe (with or without a stick)? (Required.)

Question Title

* 9. After a meal (sat at table), how painful has it been to stand up from a chair because of your knee? (Required.)

Question Title

* 10. Have you been limping when walking because of your knee? (Required.)

Question Title

* 11. Could you kneel down and get up again afterwards? (Required.)

Question Title

* 12. Are you troubled by pain in your knee at night in bed? (Required.)

Question Title

* 13. How much has pain from your knee interferes with your usual work (including housework)? (Required.)

Question Title

* 14. Have you felt your knee might suddenly give way or let you down? (Required.)

Question Title

* 15. Could you do household shopping on your own? (Required.)

Question Title

* 16. Could you walk down a flight of stairs? (Required.)

Question Title

* 17. On a scale of 1 - 10, where 10 is a perfect knee and 1 is the worst knee you could imagine, where would you rate you knee now?

1. What is your name?

2. Which knee is planned for treatment or has been treated?

3. Is this questionnaire being completed ....

4. What is today's date?

5. How would you describe the pain you usually have in your knee? (Required.)

6. Have you had any issues washing and drying yourself (all over) because of your knee? (Required.)

7. Have you had any issues getting in and out of a car or public transport because of your knee (with or without a stick)? (Required.)

8. For how long are you able to walk walk before your knee pain becomes severe (with or without a stick)? (Required.)

9. After a meal (sat at table), how painful has it been to stand up from a chair because of your knee? (Required.)

10. Have you been limping when walking because of your knee? (Required.)

11. Could you kneel down and get up again afterwards? (Required.)

12. Are you troubled by pain in your knee at night in bed? (Required.)

13. How much has pain from your knee interferes with your usual work (including housework)? (Required.)

14. Have you felt your knee might suddenly give way or let you down? (Required.)

15. Could you do household shopping on your own? (Required.)

16. Could you walk down a flight of stairs? (Required.)

17. On a scale of 1 - 10, where 10 is a perfect knee and 1 is the worst knee you could imagine, where would you rate you knee now?