Itâ€™s critical to understand, monitor, and judge the level of your knee pain and current functionality. This way, you and your doctor can assess whether a knee replacement or other treatment is right for you. The questions below will help you and your clinician understand the severity of your knee condition.

On each question, rate yourself on a scale of 1 to 5. When totaled, your score will tell you whether youâ€™re a potential candidate for a total or partial knee replacement. Consider printing the questionnaire and marking your responses so that you can share it with your doctor.

## 1. Your overall level of pain:

1 = slight pain and/or no trouble

2 = slight pain and/or little trouble

3 = moderate pain and/or moderate trouble

4 = serious pain and/or extreme difficulty

5 = severe pain and/or impossible

## 2. Pain and difficulty bathing and drying yourself:

1 = slight pain and/or no trouble

2 = slight pain and/or little trouble

3 = moderate pain and/or moderate trouble

4 = serious pain and/or extreme difficulty

5 = severe pain and/or impossible

## 3. Pain and difficulty getting in and out of a car, operating a vehicle, or using public transportation:

1 = slight pain and/or no trouble

2 = slight pain and/or little trouble

3 = moderate pain and/or moderate trouble

4 = serious pain and/or extreme difficulty

5 = severe pain and/or impossible

## 4. Indicate the length of time youâ€™re able to walk before experiencing severe knee pain (with or without a cane):

1 = longer than 30 minutes

2 = 16-30 minutes

3 = 5-15 minutes

4 = less than 5 minutes

5 = canâ€™t walk without severe pain

## 5. After sitting in a chair or at a table and then getting up to stand, what level of pain do you experience?

1 = slight pain and/or no trouble

2 = slight pain and/or little trouble

3 = moderate pain and/or moderate trouble

4 = serious pain and/or extreme difficulty

5 = severe pain and/or impossible

## 6. Does the pain in your knee cause you to limp while walking?

1 = rarely or never

2 = occasionally, or only when first starting walking

3 = frequently

4 = the majority of the time

5 = always

## 7. Are you able to kneel down and get back up easily afterwards?

1 = yes, without any problem

2 = yes, with slight difficulty

3 = yes, with moderate difficulty

4 = yes, with extreme difficulty

5 = not possible

## 8. Does your knee pain interfere with sleep?

1 = never

2 = once in a while

3 = some nights

4 = most nights

5 = every night

## 9. Are you able to work and do housework?

1 = yes, with minimal or no problem

2 = yes, most of the time

3 = yes, fairly often

4 = sometimes

5 = rarely or never

## 10. Does your knee ever feel as though itâ€™s going to give way?

1 = not at all

2 = occasionally

3 = fairly often

4 = most of the time

5 = all of the time

## 11. Are you able to do household shopping?

1 = yes, with minimal or no problem

2 = yes, most of the time

3 = yes, fairly often

4 = sometimes

5 = rarely or never

## 12. Are you able to walk down a flight of stairs?

1 = yes, with minimal or no problem

2 = yes, most of the time

3 = yes, fairly often

4 = sometimes

5 = rarely or never