Kaiser IKDC SUBJECTIVE KNEE EVALUATION FORM - 17JUL19


For an upcoming appointment with AARON BRADLEY CULLEN MD on 7/12/2019

What is the highest level of activity that you can perform without significant knee pain?? 
very strenuous (jumping, karate)
strenuous (heavy physical, moving boxes)
moderate (running)
***light activity (walking)***
unable to do anything

During the past 4 weeks, or since your injury, how often have you had pain? (where 0=Never and 10=Constant)
***9*** (there are moments of no pain, but typically pain bent, straignt, awake, asleep (wakes me up)

If you have pain, how severe is it? (where 0=No pain and 10=Worst pain imaginable)
***9*** (10 <--> 4 broken ribs; 9 <--> leg colapses)

During the past 4 weeks, or since your injury, how stiff or swollen was your knee?
swollen: *** Not at all *** mildly - moderately  - very - extremely
Stiff: Not at all *** mildly *** moderately  - very - extremely

What is the highest level of activity you can perform without significant swelling in your knee?
***very strenuous (jumping, karate)***
strenuous (heavy physical, moving boxes)
moderate (running)
light activity (walking)
unable to do anything

During the past 4 weeks, or since your injury, did your knee lock or catch?
NO

What is the highest level of activity you can perform without significant giving way in your knee?
very strenuous (jumping, karate)
strenuous (heavy physical, moving boxes)
moderate (running)
light activity (walking)
***unable to do anything***... without knee colapsing, but, do them anyway

What is the highest level of activity you can participate in on a regular basis?
***very strenuous (jumping, karate)***
strenuous (heavy physical, moving boxes)
moderate (running)
light activity (walking)
unable to do anything

How does your knee affect your ability to:
Go up stairs
***Not difficult at all*** - there are no stairs in my world
minimally difficult
moderately difficult
extremely difficult
unable to do
Go down stairs
***Not difficult at all*** - there are no stairs in my world,
but, walking downhill has been a problem for the last 20 years
minimally difficult
moderately difficult
extremely difficult
unable to do
Kneel on the front of your knee
***Not difficult at all*** - just do it slowly
minimally difficult
moderately difficult
extremely difficult
unable to do
Squat
***Not difficult at all*** - doesn't bend as much as left titanium knee
minimally difficult
moderately difficult
extremely difficult
unable to do
Sit with your knee bent
***Not difficult at all*** - but straighten directly, then bend... then straighten
minimally difficult
moderately difficult
extremely difficult
unable to do
Rise from a chair
***Not difficult at all***
minimally difficult
moderately difficult
extremely difficult
unable to do
Run straight ahead
***Not difficult at all***
minimally difficult
moderately difficult
extremely difficult
unable to do
Jump and land on your involved leg
Not difficult at all
minimally difficult
moderately difficult
***extremely difficult*** - good chance of a colapse
unable to do
Start and stop quickly
***Not difficult at all*** huh???
minimally difficult
moderately difficult
extremely difficult
unable to do

FUNCTION PRIOR TO YOUR KNEE INJURY (where 0=Couldn't perform and 10=No limitation)
10

CURRENT FUNCTION OF YOUR KNEE INJURY (where 0=Can't perform and 10=No limitation)
3

KF!