Patient Self-Evaluation

NAME: ______

DATE: ______

AGE: ______

KNEE

PATIENT SELF-EVALUATION

Which knee hurts? /

L R

/ Both
Do you have pain in the knee at night? /

YES

NO

Do you take pain medication (ibuprofen, Tylenol, etc.)? /

YES

/ NO
Do you take narcotic pain medication (lortab, codeine)? /

YES

How many pills do you take per day on average? / ______/ Pills per day

How severe is your pain in your knee on average? (please circle one)

NONE

SLIGHT

OR
OCCASSIONAL /

MILD

Only after heavy activities /

MODERATE

After light activities /

MARKED

Present all the time, requires medications /

TOTALLY

DISABLING

ACTIVITIES OF DAILY LIVING

Circle the number in the box that indicates your ability to do the following activities
0 = unable to perform; 1 = very difficult; 2 = somewhat difficult; 3 = not difficult

Activity

Left leg

Right leg

1. Walk one block? / 0 1 2 3 / 0 1 2 3
2. Sleep through the night? / 0 1 2 3 / 0 1 2 3
3. Walk one mile? / 0 1 2 3 / 0 1 2 3
4. Kneel down on your knees? / 0 1 2 3 / 0 1 2 3
5. Climb one flight of stairs? / 0 1 2 3 / 0 1 2 3
6. Jog a short distance (1/4 mile)? / 0 1 2 3 / 0 1 2 3
7. Sprint at top speed? / 0 1 2 3 / 0 1 2 3
8. Ride in car / Sit in movie for one hour? / 0 1 2 3 / 0 1 2 3
9. Perform usual work – specify: / 0 1 2 3 / 0 1 2 3
10. Perform usual sport – specify: / 0 1 2 3 / 0 1 2 3

SATISFACTION QUESTIONAIRE

Are you pleased satisfied with the condition of your knee? / YES / NO
Would you have the surgery again? / YES / NO

COMMENTS: