• You and your knees
  • Your fitness level
  • Previous treatments
  • Your treatment goals

How long have you been experiencing knee pain?

Have you been diagnosed with osteoarthritis of the knee(s)?

How would you describe your level of knee pain?

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How satisfied are you with your ability to exercise?

How would you rate your level of knee pain during the following activities?

  • (1 = Least Pain, 5 = Most Pain)

    • 1
    • 2
    • 3
    • 4
    • 5

  • Activity

  • Sitting

  • Standing

  • Walking

  • Going up and down stairs

  • At night resting in bed

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Which treatments have you tried?
(select all that apply)

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Osteoarthritis of the knee can limit your ability to participate in your usual daily activities, such as going to work, getting around, taking care of chores, running errands or going out with your friends or family.

What are the most important activities you’d like to get back to:

Other notes or questions you’d like to include in your report:

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Summary

  • How long have you been experiencing knee pain?

    Your answer:

  • Have you been diagnosed with osteoarthritis of the knee(s)?

    Your answer:

  • How would you describe your level of knee pain?

    Your answer:

  • How satisfied are you with your ability to exercise?

    Your answer:

  • How would you rate your level of knee pain during the following activities?

    Your answer:

    • Activity:

    • Sitting:

    • Standing:

    • Walking:

    • Going up and down stairs:

    • At night resting in bed:

  • Which osteoarthritis treatments have you tried?
    (select all that apply)

    Your answer:

  • What are the most important activities you’d like to get back to:

    Your answer:

  • Include any other notes or questions you’d like to include on your report:

    Your answer: