First name
*
Last name
*
Email address
*
Date of birth
*
How would you describe the pain you usually have from your knee?
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None
Very mild
Mild
Moderate
Severe
Have you had any trouble with washing and drying yourself (all over) because of your knee?
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No trouble at all
Very little trouble
Moderate trouble
Extreme difficulty
Impossible to do
Have you had any trouble getting in and out of a car or using public transport because of your knee? (whichever you would tend to use)
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No trouble at all
Very little trouble
Moderate trouble
Extreme difficulty
Impossible to do
For how long have you been able to walk before pain from your knee becomes severe? (with or without a stick)
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No pain/more than 30 minutes
16 to 30 minutes
5 to 15 minutes
Around the house only
Not at all - pain severe when walking
Have you been limping when walking, because of your knee?
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Rarely/never
Sometimes, or just at first
Often, not just at first
Most of the time
All of the time
Could you kneel down and get up again afterwards?
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Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible
Have you been troubled by pain from your knee in bed at night?
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No nights
Only 1 or 2 nights
Some nights
Most nights
Every night
How much has pain from your knee interfered with your usual work (including housework)?
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Not at all
A little bit
Moderately
Greatly
Totally
Have you felt that your knee might suddenly 'give way' or let you down?
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Rarely/never
Sometimes, or just at first
Often, not just at first
Most of the time
All of the time
Could you do the household shopping on your own?
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Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible
Could you walk down one flight of stairs?
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Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible
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