Knee Replacement Questionnaire


Prior to completing the questionnaire please complete the following questions:

Patient initials

Date of birth

Time from surgery

Email

Do you consent to sharing your data with the Wales hip and knee team. (Any outcomes or research using your data that is published publically will be anonymised).

On which side of your body is the affected knee for which you are receiving treatment? If you select both, please note that you will need to answer each question once for your left side and once for your right side.


During the last four weeks…

Q1. How would you describe the pain you usually have from your knee(s)?

Left Knee






Right Knee







Q2. Have you had any trouble with washing and drying yourself (all over) because of your knees?

Left Knee






Right Knee







Q3. Have you had any trouble getting in and out of a car or using public transport because of your (left/right) knee?

Left Knee






Right Knee







Q4. For how long have you been able to walk before pain from your knee(s) becomes severe? (with or without a stick)

Left Knee






Right Knee







Q5. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your knee(s)?

Left Knee






Right Knee







Q6. Have you been limping when walking, because of your knee(s)?

Left Knee






Right Knee







Q7. Could you kneel down and get up again afterwards?

Left Knee






Right Knee







Q8. Have you been troubled by pain from your knee(s) in bed at night?

Left Knee






Right Knee







Q9. How much has pain from your knee(s) interfered with your usual work (including housework)?

Left Knee






Right Knee







Q10. Have you felt that your knee(s) might suddenly 'give way' or let you down?

Left Knee






Right Knee







Q11. Could you do the household shopping on your own?












Q12. Could you walk down one flight of stairs?

Left Knee






Right Knee