Self Assessment Quiz

1. Consider all the ways your knee (hip) affects you, and then on a scale of 1 to 10 enter the number below which most represents how you feel.
0=Very Poor, 10=Excellent

2. Where does it hurt?

A. Knee
B. Both Knees
C. Hip
D. Both Hips

3. How often does your joint hurt?

A. Everyday
B. Several days a week
C. One day a week
D. Less than one day a week
E. Never

4. During the past month, how far could you walk comfortably without feeling any soreness or pain in your knee (hip)?

A. Under half a mile
B. Half a mile
C. Over 1 mile
D. Over 2 miles
E. Over 5 miles

5. During the past month, how would you describe the usual pain in your sore knee (hip) at rest?

A. Very severe
B. Severe
C. Moderate
D. Mild
E. None

6. During the past month, how would you describe the usual pain in your sore knee (hip) part when you are doing activities?

A. Very severe
B. Severe
C. Moderate
D. Mild
E. None

7. During the past month, how often did the pain in your knee (hip) make it difficult for you to sleep at night?

A. Everyday
B. Several days a week
C. One day a week
D. Less than one day a week
E. Never

8. During the past month, how often have you had severe pain in your knee (hip)?

A. Everyday
B. Several days a week
C. One day a week
D. Less than one day a week
E. Never

9. How would you describe your ability to use your knee (hip) joint during daily personal and househod activities such as dressing, walking, climbing stairs, household chores, etc.?

A. Very severe limitation
B. Severe limitation
C. Moderate limitation
D. Mild limitation
E. No limitation

10. During the past month, how much difficulty have you had in the activity below due to your knee (hip)?

Climbing stairs

A. Unable
B. Severe difficulty
C. Moderate difficulty
D. Mild difficulty
E. No difficulty

11. During the past month, how much difficulty have you had in the activity below due to your knee (hip)?

Descending stairs

A. Unable
B. Severe difficulty
C. Moderate difficulty
D. Mild difficulty
E. No difficulty

12. During the past month, how much difficulty have you had in the activity below due to your knee (hip)?

Getting in and out of the car

A. Unable
B. Severe difficulty
C. Moderate difficulty
D. Mild difficulty
E. No difficulty

13. During the past month, how much difficulty have you had in the activity below due to your knee (hip)?

Bending down to pick up something you dropped on the ground

A. Unable
B. Severe difficulty
C. Moderate difficulty
D. Mild difficulty
E. No difficulty

14. During the past month, how much difficulty have you had in the activity below due to your knee (hip)?

Lifting or carrying a full bag of groceries (8 to 10 pounds)

A. Unable
B. Severe difficulty
C. Moderate difficulty
D. Mild difficulty
E. No difficulty

15. Considering all the ways you use your knee (hip) during recreational or athletic activities (i.e. baseball, golf, aerobics, etc.), how would you describe the function of your knee (hip)?

A. Very severe limitation
B. Severe limitation
C. Moderate limitation
D. Mild difficulty
E. No difficulty

16. List one activity (recreational or athletic) below that you enjoy doing, and then select the degree of limitation you have, due to your knee (hip)?

A. Very severe limitation
B. Severe limitation
C. Moderate limitation
D. Mild difficulty
E. No difficulty

17. During the past month, what's been your main form of work?

A. Paid work
B. Housework
C. Schoolwork
D. Unemployed
E. Disabled due to your knee (hip)
F. Disabled secondary to other causes
G. Retired

If you answered D, E, F, or G to question 17, please skip questions 18 to 21, and then go to question 22. Please note if you answered A, B, C to quetion 17 please answer all questions below.

18. During the past month, how often were you unable to do any of your usual work because of your knee (hip)?

A. Everyday
B. Several days a week
C. One day a week
D. Less than one day a week
E. Never

19. During the past month, on the days you worked, how often were you unable to do your work as carefully or efficiently as you'd like because of your knee (hip)?

A. Everyday
B. Several days a week
C. One day a week
D. Less than one day a week
E. Never

20. During the past month, on days you worked, how often did you have to work a shorter day because of your knee (hip)?

A. Everyday
B. Several days a week
C. One day a week
D. Less than one day a week
E. Never

21. During the past month, on days you worked, how often did you have to change the way that your usual work is done because of your knee (hip)?

A. Everyday
B. Several days a week
C. One day a week
D. Less than one day a week
E. Never

22. Please rank the two areas in which you would most like to see improvement (place a 1 for most important, a 2 for the second most important, etc.)

Scoring
Your points will be added up using the scale below (omitting questions 1,2, 17 and 22)

A= 5
B= 4
C= 3
D= 2
E= 1