PROBLEMS WITH YOUR KNEE ?
Your Details	
GP Practice:	
 
	GP:	  	
Your Name:	
 
	Your Date of Birth:	  	
Your Address:	
  	Your Contact Telephone Number:	  	
Your NHS Number:	  	Date You Completed This Questionnaire:	

During the Past 4 weeks…						Tick one box for each question	
1	How would you describe the pain you usually have from your knee?

None			Very Mild		Mild		Moderate		Severe
											
(4)			(3)			(2)		(1)			(0)	
2	Have you had any trouble with washing and drying yourself (all over) because of your knee?

No Trouble		Very Little		Moderate 	Extreme		Impossible
At All			Trouble		Trouble	Difficulty		To Do
											
(4)			(3)			(2)		(1)			(0)	
3	Have you had any trouble getting in and out of a car or using public transport because of your knee? (whichever you would normally use)

No Trouble		Very Little		Moderate 	Extreme		Impossible
At All			Trouble		Trouble	Difficulty		To Do
											
(4)			(3)			(2)		(1)			(0)	
4	For how long have you been able to walk before pain from your knee becomes severe? (with or without walking aid like a stick/frame)

No Pain/		16 to 30		5 to 15	 	Around the		Not At All
More Than 30		Minutes		Minutes	House Only		Pain Severe
Minutes										When Walking
											
(4)			(3)			(2)		(1)			(0)	
5	After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your knee?

Not At All		Slightly			Moderately 	Very 			Unbearable
Painful			Painful			Painful		Painful			
											
(4)			(3)			(2)		(1)			(0)
Please Turn Over – More Questions Overleaf…	
6	Have you been limping when walking, because of your knee?

Rarely/			Sometimes		Often, Not 	Most Of		All Of 
Never			Or Just At		Just At		The Time		The Time				First			First
											
(4)			(3)			(2)		(1)			(0)	
7	Could you kneel down and get up again afterwards?

Very 			With Little	With Moderate 	With Extreme		No
Easily			Trouble	Difficulty		Difficulty		Impossible
											
(4)			(3)		(2)			(1)			(0)	
8	Have you been troubled by pain from your knee in bed at night?

No			Only 1	or 2	Some		 	Most			Every
Nights			Nights		Nights			Nights			Night
											
(4)			(3)		(2)			(1)			(0)	
9	How much has pain from your knee interfered with your usual work (including housework)?

Not At			A Little		Moderately	 	Greatly			Totally
All			Bit					
											
(4)			(3)		(2)			(1)			(0)	
10	Have you felt that your knee might suddenly “give way” or let you down?

Rarely/			Sometimes	Often		 	Most Of		All Of
Never			Or Just		Not Just		The Time		The Time
			At First		At First						
											
(4)			(3)		(2)			(1)			(0)	
11	Could you do the household shopping on your own?

Yes			With Little	With Moderate	 	With Extreme		No
Easily			Difficulty	Difficulty		Difficulty		Impossible
											
(4)			(3)		(2)			(1)			(0)	
12	Could you walk down one flight of stairs?

Yes			With Little	With Moderate	 	With Extreme		No
Easily			Difficulty	Difficulty		Difficulty		Impossible
											
(4)			(3)		(2)			(1)			(0)	
Thank you for completing this questionnaire, please give this sheet to 
the Physiotherapist or Reception\your GP at your practice

For Practice Use Only	
Calculated Oxford Hip Score For Patient Name: