Knee Evaluation Form printable pdf download

2000 IKDC SUBJECTIVE KNEE EVALUATION FORM

Name: ____________________________________________ Date of Birth: _______________________

Todays date: ___/____/_____

Date of Injury: ____/____/_____

Symptoms

Grade symptoms at the highest activity level at which you think you could function without significant

symptoms, even if you are not actually performing activities at this level.

1. What is the highest level of activity that you can perform without significant knee pain?

Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running, or jogging

Light activities like walking, housework or yard work

Unable to perform any of the above activities due to knee pain

2. During the past 4 weeks, or since our injury, how often have you had pain?

Never

Constant

3. If you have pain, how severe is it?

No Pain

Worst Pain Imaginable

4. During the past 4 weeks, or since your injury, how stiff or swollen was your knee?

Not at all

Mildly

Moderately

Very

Extremely

5. What is the highest level of activity you can perform without significant swelling in your knee?

Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running, or jogging

Light activities like walking, housework or yard work

Unable to perform any of the above activities due to knee pain

6. During the past 4 weeks, or since your injury, did your knee lock or catch?

Yes

7. What is the highest level of activity you can perform without significant giving way in your knee?

Very strenuous activities like jumping or pivoting as in basketball or soccer

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running, or jogging

Light activities like walking, housework or yard work

Unable to perform any of the above activities due to knee pain

Knee Evaluation Form