| Question |
Answer |
Points |
| Today's Date |
|
|
| Date of birth |
|
|
| Height |
|
|
| weight |
|
|
| sex |
|
|
| Side of this (symptomatic) knee |
|
|
| Ethinicity |
|
|
| Expected Surgery Date |
|
|
| Name of Surgeon |
|
|
| Will this be a primary or revision knee replacement? |
|
|
| Charnley Functional Classification |
|
|
| ---- |
---- |
---- |
| Question |
Answer |
Points |
| Alignment: measured on AP standing Xray(Anatomic Alignment) |
|
|
| Medial / Lateral Instability: measured in full extension |
|
|
| Anterior / Posterior Instability: measured at 90 degrees |
|
|
| Range of motion |
|
|
| Flexion Contracture |
|
|
| Extensor Lag |
|
|
| Pain with level walking |
|
|
| Pain with stairs or inclines |
|
|
| Does this knee feel "normal" to you? |
|
|
| |
|
|
| How satisfied are you with the pain level of your knee while sitting? |
|
|
| How satisfied are you with the pain level of your knee while lying in bed? |
|
|
| How satisfied are you with your knee function while getting out of bed? |
|
|
| How satisfied are you with your knee function while performing light household duties? |
|
|
| How satisfied are you with your knee function while performing leisure recreational activities? |
|
|
| |
|
|
| Do you expect your knee joint replacement surgery will relieve your knee pain? |
|
|
| Do you expect your surgery will help you carry out your normal activities of daily living? |
|
|
| Do you expect you surgery will help you perform leisure recreational or sports activities? |
|
|
| |
|
|
| Can you walk without any aids (such as a cane crutches or wheelchair)? |
|
|
| If no which of the following aid(s) do you use? |
|
|
| Do you use these aid(s) because of your knees? |
|
|
| For how long can you stand (with or without aid) before sitting due to knee discomfort? |
|
|
| For how long can you walk (with or without aid) before sitting due to knee discomfort? |
|
|
| Walking on an uneven surface |
|
|
| Turning or pivoting on your leg |
|
|
| Climbing up or down a flight of stairs |
|
|
| Getting up from a low couch or a chair without arms |
|
|
| Getting into or out of a car |
|
|
| Moving laterally (stepping to the side) |
|
|
| Climbing a ladder or step stool |
|
|
| Carrying a shopping bag for a block |
|
|
| Squatting |
|
|
| Kneeling |
|
|
| Running |
|
|
| |
|
|
| |
|
|
| |
|
|
| |
|
|
| OBJECTIVE KNEE INDICATORS TOTAL SCORE |
---- |
|
| PATIENT SATISFACTION TOTAL SCORE |
---- |
|
| PATIENT EXPECTATIONS TOTAL SCORE |
---- |
|
| FUNCTIONAL ACTIVITIES TOTAL SCORE |
---- |
|