It’s critical to understand, monitor, and judge the level of your knee pain and current functionality, so that you and your doctor can assess whether a knee replacement or another treatment is right for you. The questions below will help you and your clinician understand the severity of your condition.
On each question, rate yourself on a scale of 1 to 5. When totaled, your score will tell you whether you’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 the 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 you’re able to walk before experiencing severe knee pain (with or without a cane):
1= >30 min
2= 16-30 minutes
3= 5-15 minutes
4= Less than five minutes
5= Can’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. Do you limp because of your knee and, if so, what is the severity of the limp?
1= Not at all
2= Sometimes or only at first
3= Often
4= Most of the time
5= Constantly
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 the 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/or do housework?
1= Not at all
2= Occasionally
3= Fairly often
4= Most of the time
5= All the time
10. Does your knee ever feel as though it’s going to give way?
1= Not at all
2= Occasionally
3= Fairly often
4= Most of the time
5= All 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
Final Score = ______________ (Add your score from above.)
Results
- 54 or higher: Indicates that your condition is fairly severe.
- 43 to 53: Indicates a moderate problem.
- 30 to 42: Indicates some problem or inhibited function.
- 18 to 29: Indicates that your condition is relatively mild.
- 18 or lower: Indicates that you have little to no knee problems.
