1) What is your overall level of pain:

1 = Slight pain and/or no trouble
2 = Slight pain and/or little trouble
3 = Moderate pain and/or moderate trouble
4 = Serious pain and/or extreme difficulty
5 = Severe pain and/or impossible

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2) Do you experience pain and difficulty bathing and drying yourself:

1 = Slight pain and/or no trouble
2 = Slight pain and/or little trouble
3 = Moderate pain and/or moderate trouble
4 = Serious pain and/or extreme difficulty
5 = Severe pain and/or impossible

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3) Do you experience pain and difficulty getting in and out of a car, operating the vehicle, or using public transportation:


1 = Slight pain and/or no trouble
2 = Slight pain and/or little trouble
3 = Moderate pain and/or moderate trouble
4 = Serious pain and/or extreme difficulty
5 = Severe pain and/or impossible

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4) Indicate the length of time you're able to walk before experiencing severe knee pain (with or without a cane):

1 = more than 30 minutes
2 = 16-30 minutes
3 = 5-15 minutes
4 = Less than five minutes
5 = Can't walk without severe pain

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5) After sitting in a chair or at a table and then getting up to stand, what level of pain do you experience?

1 = Slight pain and/or no trouble
2 = Slight pain and/or little trouble
3 = Moderate pain and/or moderate trouble
4 = Serious pain and/or extreme difficulty
5 = Severe pain and/or impossible

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6) If you limp because of your knee and, what is the severity of the limp?

1 = Not at all
2 = Sometimes or only at first
3 = Often
4 = Most of the time
5 = Constantly

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7) Are you able to kneel down and get back up easily afterward?

1 = Yes, without any problem
2 = Yes, with slight difficulty
3 = Yes, with moderate difficulty
4 = Yes, with extreme difficulty
5 = Not possible

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8) Does the knee pain ever interfere with sleep?

1 = Never
2 = Once in a while
3 = Some nights
4 = Most nights
5 = Every night

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9) Does your knee pain prevent you from working and/or doing housework?

1 = Not at all
2 = Occasionally
3 = Fairly often
4 = Most of the time
5 = All the time

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10) Does your knee ever feel as though it's going to give way?

1 = Not at all
2 = Occasionally
3 = Fairly often
4 = Most of the time
5 = All the time

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11) Are you able to do household shopping?

1= Yes, with minimal or no problem
2= Yes, most of the time
3= Yes, fairly often
4= Sometimes
5= Rarely or never

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12) Are you able to walk down a flight of stairs?

1 = Yes, with minimal or no problem
2 = Yes, most of the time
3 = Yes, fairly often
4 = Sometimes
5 = Rarely or never

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Final Score =

Results
54 or higher: Indicates that your condition is fairly severe.
43 to 53: Indicates a moderate problem.
30 to 42: Indicates some problem or inhibited function.
18 to 29: Indicates that your condition is relatively mild.
18 or lower: Indicates that you have little to no knee problems.

Anything else you would like to let us know?