Demographic Information








8. Please indicate the expected date and surgeon for your knee replacement operation





OBJECTIVE KNEE INDICATORS

Alignment


Instability



Joint Motion


4. b) Deductions

Symptoms

OBJECTIVE KNEE INDICATORS TOTAL SCORE:
  


PATIENT SATISFACTION

PATIENT SATISFACTION TOTAL SCORE:
  


PATIENT EXPECTATIONS

What do you expect to accomplish with your knee replacement:

PATIENT EXPECTATIONS TOTAL SCORE:
  


FUNCTIONAL ACTIVITIES

Walking And Standing

Standard Activities

How much does your knee bother you during each of the following activities?

Advanced Activities

How much does your knee bother you during each of the following activities?

Discretionary Knee Activities

How much does your knee bother you during these activities?

FUNCTIONAL ACTIVITIES TOTAL SCORE: