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Knee Pain Assessment Survey

This document contains an 8 question questionnaire for a patient about pain in the kneecap region. It asks the patient to rate on a scale of 0-10 for things like pain while sitting, walking downstairs, squatting, and doing activities like lunges and single leg hops. It also asks about current activity levels and ability to do physical activity/sports with or without pain. The patient is to fill in their name, date, and scores for each question with the total score calculated out of 100.

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905 views2 pages

Knee Pain Assessment Survey

This document contains an 8 question questionnaire for a patient about pain in the kneecap region. It asks the patient to rate on a scale of 0-10 for things like pain while sitting, walking downstairs, squatting, and doing activities like lunges and single leg hops. It also asks about current activity levels and ability to do physical activity/sports with or without pain. The patient is to fill in their name, date, and scores for each question with the total score calculated out of 100.

Uploaded by

vxhfvqjkpk
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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VISA-P QUESTIONNAIRE

Patient Name: ___________________________________ Instructions: In this questionnaire, the term


Date: ____________________________________________ "pain" refers specifically to pain in the knee cap
region

1. For how many minutes can you sit pain free?


0 100
minutes 0 1 2 3 4 5 6 7 8 9 10 minutes

2. Do you have pain walking downstairs with a normal gait cycle?


Strong No
severe pain 0 1 2 3 4 5 6 7 8 9 10 pain

3. Do you have pain at the knee with full active non-weightbearing knee extension?
Strong No
severe pain 0 1 2 3 4 5 6 7 8 9 10 pain

4. Do you have pain when doing a full weight bearing lunge?


Strong No
severe pain 0 1 2 3 4 5 6 7 8 9 10 pain

5. Do you have problems squatting?


Unable No
to do 0 1 2 3 4 5 6 7 8 9 10 problems

6. Do you have pain during or immediately after doing 10 single leg hops?
Strong No
severe pain 0 1 2 3 4 5 6 7 8 9 10 pain
7. Are you currently undertaking sport or other physical activity?

0 Not at all

4 Modified training ± modified competition

7 Full training ± competition but not at same level as when symptoms began

10 Competing at the same or higher level as when symptoms began

8. Please complete EITHER A, B or C in this question.


If you have no pain while undertaking sport please complete Q8a only.
If you have pain while undertaking sport but it does not stop you from
completing the activity, please complete Q8b only.
If you have pain that stops you from completing sporting activities, please
complete Q8c only.

A. If you have no pain while undertaking sport, for how long can you train/practise?

NIL 1-5 minutes 6-10 minutes 7-15 minutes >15 minutes

0 7 14 21 30

B. If you have some pain while undertaking sport, but it does not stop you from
completing your training/practice for how long can you train/practise?

NIL 1-5 minutes 6-10 minutes 7-15 minutes >15 minutes

0 4 10 14 20

C. If you have pain which stops you from completing your training/practice for how
long can you train/practise?

NIL 1-5 minutes 6-10 minutes 7-15 minutes >15 minutes

0 2 5 7 10

TOTAL SCORE (______ /100) = _____%

MORE INFORMATION

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