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Name
*
Phone
*
How much pain do you have when you are walking?
*
None
Mild or Occasional
Moderate
Severe
How much pain does your knee cause when going up and down stairs?
*
None
Mild or Occasional
Moderate
Severe
How much pain does your knee cause when you are at rest?
*
None
Mild or Occasional
Moderate
Severe
How does you knee affect your walking ability?
*
I can walk unlimited distances
can walk 10-20 blocks (More than 2-4 Kms)
I can walk 5-10 blocks (1-2 Kms)
I can walk less than one block (250 Mts)
I cannot walk at all
How do you go up and down stairs?
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I go up stairs normally one foot in front of the other
I use the handrail for balance
I use handrail to pull myself up
I cannot climb stairs
How do I get out of chair?
*
I get out of a chair normally without support
I use the arm rests for balance
I use the arm rests to push myself up
I cannot get out of chair
What type of support do you use when walking?
*
None
Single cane
2 canes
Crutches
Walker
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