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Total # of Questions: 60

Knee Society Score pre-op panel [Knee Society Score] [100159-3]

Date Done

Time Done

Where Done

Comment

Name

Value

Units

Today's date [30947-6]

Birth date [21112-8]

Height (ft' in") [8302-2]

Weight (lbs.) [29463-7]

Sex [46098-0]

Side of this (symptomatic) knee [20228-3]

Ethnicity [46463-6]

Date [67782-3]

Name of Surgeon [97810-6]

Will this be a primary or revision knee replacement? [100160-1]

Charnley Functional Classification [100161-9]

Alignment: measured on AP standing Xray(Anatomic Alignment) [100162-7]

Medial / Lateral Instability: measured in full extension [100163-5]

Anterior / Posterior Instability: measured at 90 degrees [100164-3]

Range of motion (1 point for each 5 degrees) [100165-0]

Flexion Contracture [100166-8]

Extensor Lag [100167-6]

Pre-op objective knee indicators score [100198-1]

Pain with level walking [100168-4]

Pain with stairs or inclines [100169-2]

Does this knee feel "normal" to you? [100170-0]

Pre-op symptoms score [100199-9]

Currently, how satisfied are you with the pain level of your knee while sitting? [100171-8]

Currently, how satisfied are you with the pain level of your knee while lying in bed? [100172-6]

Currently, how satisfied are you with your knee function while getting out of bed? [100173-4]

Currently, how satisfied are you with your knee function while performing light household duties? [100174-2]

Currently, how satisfied are you with your knee function while performing leisure recreational activities? [100175-9]

Pre-op patient satisfaction score [100292-2]

Do you expect your knee joint replacement surgery will relieve your knee pain? [100176-7]

Do you expect your surgery will help you carry out your normal activities of daily living? [100177-5]

Do you expect you surgery will help you perform leisure, recreational or sports activities? [100178-3]

Pre-op patient expectations score [100200-5]

Can you walk without any aids (such as a cane, crutches or wheelchair)? [100179-1]

If no, which of the following aid(s) do you use? [100180-9]

Do you use these aid(s) because of your knees? [100181-7]

For how long can you stand (with or without aid) before sitting due to knee discomfort? [100182-5]

For how long can you walk (with or without aid) before stopping due to knee discomfort? [100183-3]

How much does your knee bother you during each of the following activities? Walking on an uneven surface [100184-1]

How much does your knee bother you during each of the following activities? Turning or pivoting on your leg [100185-8]

How much does your knee bother you during each of the following activities? Climbing up or down a flight of stairs [100186-6]

How much does your knee bother you during each of the following activities? Getting up from a low couch or a chair without arms [100187-4]

How much does your knee bother you during each of the following activities? Getting into or out of a car [100188-2]

How much does your knee bother you during each of the following activities? Moving laterally (stepping to the side) [100189-0]

How much does your knee bother you during each of the following activities? Climbing a ladder or step stool [100190-8]

How much does your knee bother you during each of the following activities? Carrying a shopping bag for a block [100191-6]

How much does your knee bother you during each of the following activities? Squatting [100192-4]

How much does your knee bother you during each of the following activities? Kneeling [100193-2]

How much does your knee bother you during each of the following activities? Running [100194-0]

Pre-op functional activities score [100201-3]

Important discretionary knee activity [73985-4]

Activity & bothersome level panel [100197-3]

Activity (Please write the 3 activities from list above) [73985-4]

How much does your knee bother you during each of these activities? [100195-7]

Activity & bothersome level panel [100197-3]

Activity (Please write the 3 activities from list above) [73985-4]

How much does your knee bother you during each of these activities? [100195-7]

Activity & bothersome level panel [100197-3]

Activity (Please write the 3 activities from list above) [73985-4]

How much does your knee bother you during each of these activities? [100195-7]

Pre-op discretionary knee activities score [100202-1]

Pre-op total score [100196-5]

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