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Questionnaire for Knee Patients

Questionnaire on your Knee Symptoms

If you are scheduled to have KNEE SURGERY, then could you please complete this form prior to your procedure. Answer as many questions as you can while thinking about your pain at its worst in the past two weeks. If the question does not apply to you then leave it blank. It will assist us with a realistic assessment of the state of your knee before and after your surgery. Thank you.

- Step 1 of 8

Name *

First

Last

Date of Birth *

Today's Date *

Side *

Questions

1. TEGNER ACTIVITY LEVEL SCALE

Please indicate in the spaces below the HIGHEST level of activity that you participated in BEFORE YOUR INJURY and the highest level you are able to participate in CURRENTLY.

Level 10: Competitive sports- soccer, football, rugby (national elite)
Level 9: Competitive sports- soccer, football, rugby (lower divisions), ice hockey, wrestling, gymnastics, basketball etc
Level 8: Competitive sports- (Club or league) racquetball squash or badminton, track and field athletics (jumping, etc.), down-hill skiing, MTB etc
Level 7: Competitive sports- tennis, running, , handball, squash Recreational sports- soccer, football, rugby, ice hockey, basketball, squash, racquetball, running, MTB, dancing etc
Level 6: Recreational sports- tennis and badminton, handball, racquetball, down-hill skiing, jogging at least 5 times per week
Level 5: Work- heavy labour (construction, etc.) Competitive sports- cycling, cross-country skiing, Recreational sports- jogging on uneven ground at least twice weekly
Level 4: Work- moderately heavy labour (e.g. truck driving, mechanic etc.)
Level 3: Work- light labour (nursing, physiotherapy, waiter etc.)
Level 2: Level 2 Work- light labour Walking on uneven ground possible, but impossible to back pack or hike
Level 1: Work- sedentary (secretarial, clerical etc.)
Level 0: Sick leave or disability pension because of hip problems

Before Injury level of Activity: *

Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10

Current Level of Activity: *

Rate 1 out of 10Rate 2 out of 10Rate 3 out of 10Rate 4 out of 10Rate 5 out of 10Rate 6 out of 10Rate 7 out of 10Rate 8 out of 10Rate 9 out of 10Rate 10 out of 10

Instructions

This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to do your usual activities.

Symptoms

These questions should be answered thinking of your knee symptoms and difficulties during the last week.

S1. Do you have swelling in your knee?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Never 2.Rarely 3.Sometimes 4.Often 5.Always

S2. Do you feel grinding, hear clicking or any other type of noise when your knee moves?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Never 2.Rarely 3.Sometimes 4.Often 5.Always

S3. Does your knee catch or hang up when moving?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Never 2.Rarely 3.Sometimes 4.Often 5.Always

S4. Can you straighten your knee fully?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Never 2.Rarely 3.Sometimes 4.Often 5.Always

S5. Can you bend your knee fully?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Never 2.Rarely 3.Sometimes 4.Often 5.Always

Stiffness

The following questions concern the amount of joint stiffness you have experienced during the last week in your knee. Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint.

S6. How severe is your knee joint stiffness after first wakening in the morning?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

S7. How severe is your knee stiffness after sitting, lying or resting later in the day?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

Pain

P1. How often do you experience knee pain?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Never 2.Rarely 3.Sometimes 4.Often 5.Always

What amount of knee pain have you experienced the last week during the following activities?

P2. Twisting/pivoting on your knee

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

P3. Straightening knee fully

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

P4. Bending knee fully

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

P5. Walking on flat surface

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

P6. Going up or down stairs

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

P7. At night while in bed

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

P8. Sitting or lying

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

P9. Standing upright

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

Function, daily living

The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee.

A1. Descending stairs

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A2. Ascending stairs

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A3. Rising from sitting

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A4. Standing

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A5. Bending to the floor/pick up an object

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A6. Walking on a flat surface

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A7. Getting in/out of car

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A8. Going shopping

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A9. Putting on socks/stockings

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A10. Rising from bed

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A11. Taking off socks/stockings

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A12. Lying in bed (turning over, maintaining hip position)

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A13. Getting in/out of bath

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A14. Sitting

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A15. Getting on/off toilet

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

A17. Light domestic duties (cooking, dusting, etc)

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

Function, sports and recreational activities

The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your knee.

SP1. Squatting

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

SP2. Running

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

SP3. Jumping

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

SP4. Twisting/pivoting on your injured knee

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

SP5. Kneeling

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.None 2.Mild 3.Moderate 4.Severe 5.Extreme

Quality of Life

Q1. How often are you aware of your knee problem?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Never 2.Monthly 3.Weekly 4.Daily 5.Constantly

Q2. Have you modified your life style to avoid activities potentially damaging to your knee?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Not-at-all 2.Mildly 3.Moderately 4.Severe 5.Totally

Q3. How much are you troubled with lack of confidence in your knee?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Not-at-all 2.Mildly 3.Moderately 4.Severe 5.Extreme

Q4. In general, how much difficulty do you have with your knee?

Rate 1 out of 5Rate 2 out of 5Rate 3 out of 5Rate 4 out of 5Rate 5 out of 5

1.Not-at-all 2.Mildly 3.Moderately 4.Severe 5.Extreme

Email

Book a Consultation:

Personal Assistant to Dr Munting

Merle Hermanus

+27 21 424 0725/6

merle@ctorth.com

Settle my Account:

Accounts & Admin

Jami Damon

+27 21 424 0726

jami@ctorth.com

Find Us:

Netcare Christiaan Barnard Memorial Hospital

25 D.F. Malan St, Foreshore,

Cape Town, 8001

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