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  5. TKR Patient Survey
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Name
   
 
 
 
Surgery Date:
   
 
 
 
Time since surgery:
 
Pre-Op
 
6-Weeks
 
3-Months
 
6-Months
 
 
 
Assessment Date:
   
 
 
All of these questions refer to your symptoms and activities during the past week. This information helps us to keep track of how you feel about your knee and how well you are able to do your usual activities. Please choose the best response for each question below:
Never Rarely Sometimes Often Always
Do you have swelling in your knee?
Do you feel grinding, hear clicking?
Does your knee catch or lock up?
Can you straighten your knee fully?
Can you bend your knee fully?
 
 
For each of the following activities, please indicate the degree of difficulty you have experienced in the last week due to your knee:
None Mild Moderate Severe Extreme
Ascending stairs?
Rising from Sitting?
Walking on flat surface?
Getting in/out of car?
Putting on socks/stockings?
Rising from bed?
Sitting?
 
 
 
How far can you walk?
 
Unable
 
Homebound
 
1 to 4 blocks
 
5 to 10 blocks
 
>10 blocks
 
Unlimited
 
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