KNEE QUESTIONNAIRE

Name: *

Which side is your pain on? *

Right

Left

Bilateral

How long have you had knee pain? Left knee: Please specify how many days, weeks, months or years: _________________________________________ If injured, what is the date of injury: _______________ Right knee: Please specify how many days, weeks, months or years: _________________________________________ If injured, what is the date of injury: _______________

0/45 characters

How did the problem occur? *

0/300 characters

Are you currently working? *

Yes

No

Do you have pain every day? *

Yes

No

Do you have pain all day? *

Yes

No

Do you have swelling? *

Yes

No

Does your knee give away? *

Yes

No

Does your knee snap or pop? *

Yes

No

Do you have locking? *

Yes

No

Do you have pain sitting? *

Yes

No

Do you have pain standing? *

Yes

No

Do you have pain walking? *

Yes

No

Do you have pain going upstairs? *

Choice A

Choice B

Do you have pain going downstairs? *

Yes

No

Do you have pain walking on uneven surfaces? *

Yes

No

Do you have pain walking on hard surfaces? *

Yes

No

Are you able to kneel? *

Yes

No

Are you able to jump? *

Yes

No

Are you able to climb ladders? *

Yes

No

Are you able to run? *

Yes

No

Does your pain worsen in bad weather? *

Yes

No

Do you wear a brace? *

Yes

No

Have you had any problems before this with your knee? *

Yes

No

If yes, when did it occur?

Have you ever had knee surgery? *

Yes

No

If yes, when? By whom?

Have you had injections in the knee? *

Yes

No

If yes, when?