Please Do Not Print This Form. Thank you for completing this patient-reported outcome questionnaire. Your responses help your provider determine the best treatment options and track your recovery progress over time. Please answer each of the questions included on this form.

ALL QUESTIONS MUST BE ANSWERED

TO WHAT DEGREE DOES EACH OF THE FOLLOWING SYMPTOMS AFFECT YOUR LEVEL OF ACTIVITY?

For each row, mark the ONE box which most closely describes your current condition.

FUNCTIONAL LIMITATIONS WITH ACTIVITIES - HOW DOES YOUR KNEE AFFECT YOUR ABILITY TO:

For each row, mark the ONE box which most closely describes your current condition.