Please complete this form by answering the following questions, or go to this web address and fill it
out online, print a copy to bring with you for your appointment

Primary complaint (circle)
Please answer the following 12 multiple choice questions:
1. How would you describe the pain you usually have in your knee?
2. Have you had any trouble washing and drying yourself (all over) because of your knee?
3. Have you had any trouble getting in and out of the car or using public transport because of your knee?
4. For how long are you able to walk before the pain in your knee becomes severe?
5. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your knee?
6. Have you been limping when walking, because of your knee?
7. Could you kneel down and get up again afterwards?
8. Are you troubled by pain in your knee at night in bed?
9. How much has pain from your knee interfered with your usual work? (including housework)
10. Have you felt that your knee might suddenly “give away”?
11. Could you do household shopping on your own?
12. Could you walk down a flight of stairs?