Revision Knee Replacement Questionnaire

If you have had bilateral surgery please use one form for the left knee and one form for the right knee.

If there are reasons other than the operation which would stop you doing one of the tasks listed; try to answer the question from the joint replacement aspect alone.

Patient Name *

Joint Registry Reference (if known)

Patient Address

Date of Birth

Day

Month

Year

Operating Surgeon

Date of Surgery

Day

Month

Year

Side *

Left

Right

Question 1 - How would you describe the pain you usually have from your operated on knee? *

Question 2 - For how long have you been able to walk before the pain from your operated on knee becomes severe? (with or without a stick) *

Question 3 - Have you had any trouble getting in and out of a car or using public transport because of your operated on knee? *

Question 4 - Could you kneel down and get up again afterwards? *

Question 5 - Could you do the household shopping on your own? *

Question 6 - Have you had any trouble with washing and drying yourself (all over) because of your operated on knee? *

Question 7 - How much has pain from your operated on knee interfered with your usual work (including housework)? *

Question 8 - After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your operated on knee? *

Question 9 - Have you felt that your operated on knee might suddenly "give way" or let you down? *

Question 10 - Have you been limping when walking, because of your operated on knee? *

Question 11 - Could you walk down a flight of stairs? *

Question 12 - Have you been troubled by pain from your operated on knee in bed at night? *

Progress report

I wish to receive a progress report on the study.

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