IKDC.docx

IKDC.docx

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IKDC

2000

IKDC

KNEEFORMS

INTRODUCTION

TheentireIKDCform,whichincludesaMODEMSTMcompatibledemographicform,currenthealthassessmentform,subjectivekneeevaluationform,kneehistoryform,surgicaldocumentationform,andkneeexaminationform,maybeusedasseparateforms.ResearcherswhowanttoremainMODEMSTMcompatibleandusebenchmarkingdataarerequiredtocompletethedemographicformandcurrenthealthassessmentform.Thekneehistoryformandsurgicaldocumentationformareprovidedforconvenience.Allresearchersarerequiredtocompletethesubjectivekneeevaluationandkneeexaminationform.Instructionsforscoringthesubjectivekneeevaluationformandthekneeexaminationformareprovidedonthebackoftheforms.

TABLEOFCONTENTS

1.DemographicForm

2.CurrentHealthAssessmentForm

3.SubjectiveKneeEvaluationForm

4.KneeHistoryForm

5.SurgicalDocumentationForm

6.KneeExaminationForm

IKDCDEMOGRAPHICFORM

YourFullName______________________________________________________

YourDateofBirth_________/___________/___________

DayMonthYear

YourSocialSecurityNumber____-___-_____YourGender:

MaleFemale

Occupation__________________________________________________________

Today’sDate_____________/___________/___________

DayMonthYear

Thefollowingisalistofcommonhealthproblems.Pleaseindicate“Yes”or“No”inthefirstcolumn,andthenskiptothenextitem.Ifyoudohavetheproblem,pleaseindicateinthesecondcolumnifyoureceivemedicationsorsomeothertypeoftreatmentfortheproblem.Inthelastcolumn,indicateiftheproblemlimitsanyofyouractivities.

DoyouhaveDoyoureceiveDoesitlimit

theproblem?

treatmentforit?

youractivities?

YesNoYesNoYesNo

Heartdisease

Highbloodpressure

Asthmaorpulmonarydisease

Diabetes

Ulcerorstomachdisease

Boweldisease

Kidneydisease

Liverdisease

Anemiaorotherblooddisease

Overweight

Cancer

Depression

Osteoarthritis,degenerative

arthritis

Rheumatoidarthritis

Backpain

Lymedisease

Othermedicalproblem

Alcoholism

Page2-IKDCDEMOGRAPHICFORM

1.Doyousmokecigarettes?

Yes

No,Iquitinthelastsixmonths.

No,Iquitmorethansixmonthsago.

No,Ihaveneversmoked.

2.Yourheightcentimetersinches

3.Yourweightkilogramspounds

4.Yourrace（indicateallthatapply）

WhiteBlackorAfrican-AmericanHispanic

AsianorPacificIslanderNativeAmericanIndianOther

5.Howmuchschoolhaveyoucompleted?

LessthanhighschoolGraduatedfromhighschoolSomecollege

GraduatedfromcollegePostgraduateschoolordegree

6.Activitylevel

Areyouahighcompetitivesportsperson?

Areyouwell-trainedandfrequentlysporting?

Sportingsometimes

Non-sporting

IKDCCURRENTHEALTHASSESSMENTFORM*

YourFullName______________________________________________________

YourDateofBirth_________/___________/___________

DayMonthYear

Today’sDate_____________/___________/___________

DayMonthYear

1.Ingeneral,wouldyousayyourhealthis:

ExcellentVeryGoodGoodFairPoor

2.Comparedtooneyearago,howwouldyourateyourhealthingeneralnow?

Muchbetternowthan1yearagoSomewhatbetternowthan1yearagoAboutthesameas1yearago

Somewhatworsenowthan1yearagoMuchworsenowthan1yearago

3.Thefollowingitemsareaboutactivitiesyoumightdoduringatypicalday.Doesyourhealthnowlimityouintheseactivities?

Ifso,howmuch?

Yes,Limited

ALot

Yes,Limited

ALittle

No,NotLimited

AtAll

a.

Vigorousactivities,suchasrunning,liftingheavyobjects,participatinginstrenuoussports

b.

Moderateactivities,suchasmovingatable,pushingavacuumcleaner,bowling,orplayinggolf

c.

Liftingorcarryinggroceries

d.

Climbingseveralflightsofstairs

e.

Climbingoneflightofstairs

f.

Bending,kneelingorstooping

g.

Walkingmorethanamile

h.

Walkingseveralblocks

i.

Walkingoneblock

j.

Bathingordressingyourself

4.Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofyourphysicalhealth?

YES

NO

a.

Cutdownontheamountoftimeyouspentonworkorotheractivities

b.

Accomplishedlessthanyouwouldlike

c.

Werelimitedinthekindofworkorotheractivities

d.

Haddifficultyperformingtheworkorotheractivities（forexample,ittookextraeffort）

5.Duringthepast4weeks,haveyouhadanyofthefollowingproblemswithyourworkorotherregulardailyactivitiesasaresultofanyemotionalproblems（suchasfeelingdepressedoranxious）?

YES

NO

a.

Cutdownontheamountoftimeyouspentonworkorotheractivities

b.

Accomplishedlessthanyouwouldlike

c.

Didn’tdoworkorotheractivitiesascarefullyasusual

Page2–IKDCCURRENTHEALTHASSESSMENTFORM*

6.Duringthepast4weeks,towhatextenthasyourphysicalhealthoremotionalproblemsinterferedwithyournormalsocialactivitieswithfamily,friends,neighbors,orgroups?

NotAtAllSlightlyModeratelyQuiteaBitExtremely

7.Howmuchbodilypainhaveyouhadduringthepast4weeks?

NoneVeryMildMildModerateSevereVerySevere

8.Duringthepast4weeks,howmuchdidpaininterferewithyournormalwork（includingbothworkoutsidethehomeandhousework）?

NotatAllALittleBitModeratelyQuiteaBitExtremely

9.Thesequestionsareabouthowyoufeelandhowthingshavebeenwithyouduringthepast4weeks.

Foreachquestion,pleasegivetheoneanswerthatcomesclosesttothewayyouhavebeenfeeling.

Howmuchofthetimeduringthepast4weeks…

Allof

thetime

Mostofthetime

Agoodbitofthetime

Someofthetime

Alittleofthetime

None

ofthetime

a.Didyoufeelfullofpep?

b.Haveyoubeenverynervous?

c.Haveyoufeltcalmandpeaceful?

d.Didyouhavealotofenergy?

e.Haveyoufeltdown-heartedandblue?

f.Didyoufeelwornout?

g.Haveyoubeenahappyperson

h.Didyoufeeltired?

10.Duringthepast4weeks,howmuchofthetimehasyourphysicalhealthoremotionalproblemsinterferedwithyoursocialactivities（likevisitingwithfriends,relatives,etc.）?

AllofthetimeMostofthetimeSomeofthetimeAlittleofthetimeNoneofthetime

11.HowTRUEorFALSEiseachofthefollowingstatementsforyou?

DefinitelyTrue

MostlyTrue

Don’tKnow

MostlyFalse

DefinitelyFalse

a.

Iseemtogetsickalittleeasierthanotherpeople

b.

IamashealthyasanybodyIknow

c.

Iexpectmyhealthtogetworse

d.

Myhealthisexcellent

*ThisformincludesquestionsfromtheSF-36TMHealthSurvey.Reproducedwiththepermissionofthe

MedicalOutcomesTrust,Copyright©1992.

2000IKDCSUBJECTIVEKNEEEVALUATIONFORM

YourFullName______________________________________________________

Today’sDate:

______/_______/______DateofInjury:

______/________/_____

DayMonthYearDayMonthYear

SYMPTOMS*:

*Gradesymptomsatthehighestactivitylevelatwhichyouthinkyoucouldfunctionwithoutsignificantsymptoms,evenifyouarenotactuallyperformingactivitiesatthislevel.

1.Whatisthehighestlevelofactivitythatyoucanperformwithoutsignificantkneepain?

Verystrenuousactivitieslikejumpingorpivotingasinbasketballorsoccer

Strenuousactivitieslikeheavyphysicalwork,skiingortennis

Moderateactivitieslikemoderatephysicalwork,runningorjogging

Lightactivitieslikewalking,houseworkoryardwork

Unabletoperformanyoftheaboveactivitiesduetokneepain

2.Duringthepast4weeks,orsinceyourinjury,howoftenhaveyouhadpain?

012345678910

NeverConstant

3.Ifyouhavepain,howsevereisit?

012345678910

NopainWorstpain

imaginable

4.Duringthepast4weeks,orsinceyourinjury,howstifforswollenwasyourknee?

Notatall

Mildly

Moderately

Very

Extremely

5.Whatisthehighestlevelofactivityyoucanperformwithoutsignificantswellinginyourknee?

Verystrenuousactivitieslikejumpingorpivotingasinbasketballorsoccer

Strenuousactivitieslikeheavyphysicalwork,skiingortennis

Moderateactivitieslikemoderatephysicalwork,runningorjogging

Lightactivitieslikewalking,housework,oryardwork

Unabletoperformanyoftheaboveactivitiesduetokneeswelling

6.Duringthepast4weeks,orsinceyourinjury,didyourkneelockorcatch?

YesNo

7.Whatisthehighestlevelofactivityyoucanperformwithoutsignificantgivingwayinyourknee?

Verystrenuousactivitieslikejumpingorpivotingasinbasketballorsoccer

Strenuousactivitieslikeheavyphysicalwork,skiingortennis

Moderateactivitieslikemoderatephysicalwork,runningorjogging

Lightactivitieslikewalking,houseworkoryardwork

Unabletoperformanyoftheaboveactivitiesduetogivingwayoftheknee

Page2–2000IKDCSUBJECTIVEKNEEEVALUATIONFORM

SPORTSACTIVITIES:

8.Whatisthehighestlevelofactivityyoucanparticipateinonaregularbasis?

Verystrenuousactivitieslikejumpingor