Knee Outcome Form (KOS) – Progressive Physical Therapy

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

Name: *

First

Middle

Last

Date

Did you have surgery for this issue PRIOR to receiving physical thearpy?

Yes
No

PAIN SCORE: Over the past 24 hours, how bad has your pain been? *

Check the number that best represents your pain. 0 = NO PAIN, 10 = WORST IMAGINABLE PAIN

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.

1. PAIN *

I Do Not have this symptom
I have the symptom, but it does not affect my activity
The symptom affects my activity slightly
The symptom affects my activity moderately
The symptom affects my activity severely
The symptom prevents me from all daily activity

2. STIFFNESS *

I Do Not have this symptom
I have the symptom, but it does not affect my activity
The symptom affects my activity slightly
The symptom affects my activity moderately
The symptom affects my activity severely
The symptom prevents me from all daily activity

3. SWELLING *

I Do Not have this symptom
I have the symptom, but it does not affect my activity
The symptom affects my activity slightly
The symptom affects my activity moderately
The symptom affects my activity severely
The symptom prevents me from all daily activity

4. KNEE GIVES WAY: BUCKLING OR SHIFTS *

I Do Not have this symptom
I have the symptom, but it does not affect my activity
The symptom affects my activity slightly
The symptom affects my activity moderately
The symptom affects my activity severely
The symptom prevents me from all daily activity

5. WEAKNESS *

I Do Not have this symptom
I have the symptom, but it does not affect my activity
The symptom affects my activity slightly
The symptom affects my activity moderately
The symptom affects my activity severely
The symptom prevents me from all daily activity

6. LIMPING *

I Do Not have this symptom
I have the symptom, but it does not affect my activity
The symptom affects my activity slightly
The symptom affects my activity moderately
The symptom affects my activity severely
The symptom prevents me from all daily activity

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.

7. WALK *

8. GO UP STAIRS *

9. GO DOWN STAIRS *

10. STAND *

11. KNEEL ON FRONT OF YOUR KNEE *

12. SQUAT *

13. SIT WITH YOUR KNEE BENT *

14. RISE FROM A CHAIR *