SUBJECTIVE KNEE SCORE QUESTIONNAIRE Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form. of Number Activity Name *Date of Birth *Email Address *Phone Number *Please click on the boxes beside each statement in each section below that best describes your present knee condition. Pain *I experience no pain in my knee.I have occasional pain with strenuous sports or heavy work. I don't think that my knee is entirely normal. Limitations are mild and tolerable.There is occasional pain in my knee with light recreational sports or moderate work.I have pain brought on by sports, light recreational activities, or moderate work. Occasional pain is brought on by daily activities such as standing or kneeling.The pain I have in my knee is a significant problem with activities as simple as walking. The pain is relieved by rest. I can't participate in sports.I have pain in my knee at all times, even during walking, standing, or light work.Intensity *MildModerateSevereFrequency *ConstantIntermittentLocation *Medial (inside)Lateral (outside)Anterior (front)Posterior (back)Diffuse (all over)Occurs *KneelStandSitStairsType *SharpAchingThrobbingBurningSwelling *I experience no swelling in my knees.I have occasional swelling in my knee with strenuous sports or heavy work.There is occasional swelling with light recreational activities or moderate work.Swelling limits my participation in sports and moderate work. Occurs infrequently with simple walking or light work about 3 times a year.My knee swells after simple walking activities and light work. Rest relieves the swelling.I have severe swelling with simple walking activities. Rest does not relieve the swelling.Stiffness *NoneOccasionalFrequentConstantGrinding *NoneMildModerateSevereLocking *NoneOccasionalFrequentConstantOverall Activity Level *No limitations. I have a normal knee, and I can do everything, i.e. strenuous sports and/or heavy labor.can partake in sports including strenuous ones but at a lower level. I must guard my knee and limit the amount of heavy labor or sports.Light recreational activities are possible with RARE symptoms. I am limited to light work.No sports or recreational activities are possible. Walking activities are possible with RARE symptoms. I am limited to light work.Walking activities and daily living cause moderate problems and persistent symptoms.Walking and other daily activities cause severe problems.Walking *Normal, unlimited.Slight, mild problems.Moderate problem, flat surface up to half a mile.Severe problems, only 2-3 blocks.Severe problems, need cane or crutches.Stairs *Normal, unlimited.Slight, mild problems.Moderate problems, only 10-15 steps possible.Severe problems, require banister for support.Severe problems, only 1-5 steps without support.Running *Normal, unlimited, fully competitive.Slight, mild problems, run at half speed.Moderate problems, only 1-2 miles possible.Severe problems, only 1-3 blocks possible.Severe problems, only a few steps.Jumping and Twisting *Normal, unlimited, fully competitive.Slight, mild problems, some guarding.Moderate problems, gave up strenuous sports.Severe problems, affects all sports, always guarding.Severe problems, only light activity possible (golf/swim).Submit PAIN IS NOT A LIFESTYLE Get your quality of life back today. BOOK APPOINTMENT
