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Knee Pain Assessment Questionnaire

This document contains a 13-question knee pain assessment questionnaire. The questions ask the respondent to rate their level of knee pain on a scale of 1 to 5 in various daily activities such as walking, bathing, sitting, standing, sleeping, working and household tasks. The questionnaire aims to evaluate the severity and impact of a person's knee pain.

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Neenu Rajput
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144 views3 pages

Knee Pain Assessment Questionnaire

This document contains a 13-question knee pain assessment questionnaire. The questions ask the respondent to rate their level of knee pain on a scale of 1 to 5 in various daily activities such as walking, bathing, sitting, standing, sleeping, working and household tasks. The questionnaire aims to evaluate the severity and impact of a person's knee pain.

Uploaded by

Neenu Rajput
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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KNEE PAIN ASSESSMENT QUESTIONNAIRE

On each question, rate yourself on a scale of 1 to 5.

1. Your overall level of pain:


1 = slight pain and/or no trouble
2 = slight pain and/or Iittle 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 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 you’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 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. 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 with knee pain
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 it'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 in knee pain
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
13 how often is your knee painful
1 Never
2 Monthly
3 weekly
4 daily
5 always
14 straightening knee fully
1 none
2 mild
3 moderate
4 severe
5 extreme

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