testingnewforms

KOOS, JR

"*" indicates required fields

MM slash DD slash YYYY
MM slash DD slash YYYY
Affected Knee*

Instructions

This survey asks for your opinion about your knee and helps us to understand how well you are able to complete your usual activities. Answer each question by ticking the appropriate box (only one box for each question). If you are uncertain about how to answer a question, please give the best answer you can.

I. Stiffness

Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint. What amount of knee stiffness have you experienced the last week during the following activities?
S1. How severe is your knee stiffness after first wakening in the morning?*

II. Pain

What amount of pain have you experienced the last week during the following activities?
P1. Twisting/pivoting on your knee*
P2. Straightening knee fully*
P3. Going up or down stairs*
P4. Standing Upright*

III. Function, daily living

This section describes your ability to move around and look after yourself. For each of the following activities, please indicate the degree of difficulty you have experienced in the last week due to your knee.
A1. Rising from sitting*
A2. Bending to the floor/pick up an object*
Survey completed prior to knee replacement
Survey completed after knee replacement
MM slash DD slash YYYY

IV. Section IV is for office use only

The KOOS JR is scored by summing the raw response (range 0-28) and then converting it to an interval score using the table provided below. The interval score ranges from 0 to 100 where 0 represents total knee disability and 100 represents perfect knee health.
This field is for validation purposes and should be left unchanged.

HOOS, JR

"*" indicates required fields

MM slash DD slash YYYY
MM slash DD slash YYYY
Affected Hip

Instructions

This survey asks for your opinion about your knee and helps us to understand how well you are able to complete your usual activities. Answer each question by ticking the appropriate box (only one box for each question). If you are uncertain about how to answer a question, please give the best answer you can.

II. Pain

What amount of hip pain have you experienced the last week during the following activities?
P1. Going up or down stairs*
P2. Walking on an uneven surface*

II. Function, daily living

This section describes your ability to move around and look after yourself. For each of the following activities, please indicate the degree of difficulty you have experienced in the last week due to your hip.
A1. Rising from sitting*
A2. Bending to the floor/pick up an object*
A3. Lying in bed (turning over, maintaining hip position)*
A4. Sitting*
Survey completed prior to hip replacement
Survey completed after hip replacement
MM slash DD slash YYYY

IV. Section IV is for office use only

The HOOS JR is scored by summing the raw response (range 0-24) and then converting it to an interval score using the table provided below. The interval score ranges from 0 to 100 where 0 represents total hip disability and 100 represents perfect hip health.
This field is for validation purposes and should be left unchanged.

Oswestry Disability Index

"*" indicates required fields

MM slash DD slash YYYY
MM slash DD slash YYYY

Oswestry Disability Index - 2.1a

This questionnaire has been designed to give us information as to how your back (or leg) trouble affects your ability lo manage in everyday life. Please answer every section. Mark one box only in each section that most closely describes you today.
Section 1 - Pain Intensity*
Section 2 - Personal Care (washing, dressing, etc.)*
Section 3 - Lifting*
Section 4 - Walking*
Section 5 - Sitting*
Section 6 - Standing*
Section 7 - Sleeping*
Section 8 - Sex Life (If applicable)*
Section 9 - Social Life*
Section 10 -Traveling*
This field is for validation purposes and should be left unchanged.