IKDC.docx

1、IKDC2000IKDCKNEE FORMSINTRODUCTIONThe entire IKDC form, which includes a MODEMSTM compatible demographic form, current health assessment form, subjective knee evaluation form, knee history form, surgical documentation form, and knee examination form, may be used as separate forms. Researchers who wa

2、nt to remain MODEMSTM compatible and use benchmarking data are required to complete the demographic form and current health assessment form. The knee history form and surgical documentation form are provided for convenience. All researchers are required to complete the subjective knee evaluation and

3、 knee examination form. Instructions for scoring the subjective knee evaluation form and the knee examination form are provided on the back of the forms.TABLE OF CONTENTS1.Demographic Form2.Current Health Assessment Form3.Subjective Knee Evaluation Form4.Knee History Form5.Surgical Documentation For

4、m6.Knee Examination FormIKDC DEMOGRAPHIC FORMYour Full Name _Your Date of Birth _/_/_ Day Month YearYour Social Security Number _-_-_ Your Gender: Male FemaleOccupation _Todays Date _/_/_ Day Month YearThe following is a list of common health problems. Please indicate “Yes” or “No” in the first colu

5、mn, and then skip to the next item. If you do have the problem, please indicate in the second column if you receive medications or some other type of treatment for the problem. In the last column, indicate if the problem limits any of your activities. Do you have Do you receive Does it limit the pro

6、blem? treatment for it? your activities? Yes No Yes No Yes NoHeart disease High blood pressure Asthma or pulmonary disease Diabetes Ulcer or stomach disease Bowel disease Kidney disease Liver disease Anemia or other blood disease Overweight Cancer Depression Osteoarthritis, degenerative arthritis Rh

7、eumatoid arthritis Back pain Lyme disease Other medical problem Alcoholism Page 2 - IKDC DEMOGRAPHIC FORM1. Do you smoke cigarettes? Yes No, I quit in the last six months. No, I quit more than six months ago. No, I have never smoked.2. Your height centimeters inches3. Your weight kilograms pounds4.

8、Your race (indicate all that apply) White Black or African-American Hispanic Asian or Pacific Islander Native American Indian Other5. How much school have you completed? Less than high school Graduated from high school Some college Graduated from college Postgraduate school or degree6. Activity leve

9、l Are you a high competitive sports person? Are you well-trained and frequently sporting? Sporting sometimes Non-sportingIKDC CURRENT HEALTH ASSESSMENT FORM *Your Full Name _Your Date of Birth _/_/_ Day Month YearTodays Date _/_/_ Day Month Year1.In general, would you say your health is: Excellent V

10、ery Good Good Fair Poor2.Compared to one year ago, how would you rate your health in general now? Much better now than 1 year ago Somewhat better now than 1 year ago About the same as 1 year ago Somewhat worse now than 1 year ago Much worse now than 1 year ago3.The following items are about activiti

11、es you might do during a typical day. Does your health now limit you in these activities? If so, how much?Yes, LimitedA LotYes, LimitedA LittleNo, Not Limited At Alla.Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports b.Moderate activities, such as moving

12、a table, pushing a vacuum cleaner, bowling, or playing golf c.Lifting or carrying groceries d.Climbing several flights of stairs e.Climbing one flight of stairs f.Bending, kneeling or stooping g.Walking more than a mile h.Walking several blocks i.Walking one block j.Bathing or dressing yourself 4.Du

13、ring the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of your physical health?YESNOa.Cut down on the amount of time you spent on work or other activities b.Accomplished less than you would like c.Were limited in the kind of wor

14、k or other activities d.Had difficulty performing the work or other activities (for example, it took extra effort) 5.During the past 4 weeks, have you had any of the following problems with your work or other regular daily activities as a result of any emotional problems (such as feeling depressed o

15、r anxious)?YESNOa.Cut down on the amount of time you spent on work or other activities b.Accomplished less than you would like c.Didnt do work or other activities as carefully as usual Page 2 IKDC CURRENT HEALTH ASSESSMENT FORM *6.During the past 4 weeks, to what extent has your physical health or e

16、motional problems interfered with your normal social activities with family, friends, neighbors, or groups? Not At All Slightly Moderately Quite a Bit Extremely7.How much bodily pain have you had during the past 4 weeks? None Very Mild Mild Moderate Severe Very Severe8.During the past 4 weeks, how m

17、uch did pain interfere with your normal work (including both work outside the home and housework)? Not at All A Little Bit Moderately Quite a Bit Extremely9.These questions are about how you feel and how things have been with you during the past 4 weeks.For each question, please give the one answer

18、that comes closest to the way you have been feeling. How much of the time during the past 4 weeksAll ofthe timeMost of the timeA good bit of the timeSome of the timeA little of the timeNoneof the timea. Did you feel full of pep? b. Have you been very nervous? c. Have you felt calm and peaceful? d. D

19、id you have a lot of energy? e. Have you felt down-hearted and blue? f. Did you feel worn out? g. Have you been a happy person h. Did you feel tired? 10.During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting

20、with friends, relatives, etc.)? All of the time Most of the time Some of the time A little of the time None of the time11.How TRUE or FALSE is each of the following statements for you?Definitely TrueMostly TrueDont KnowMostly FalseDefinitely Falsea.I seem to get sick a little easier than other peopl

21、e b.I am as healthy as anybody I know c.I expect my health to get worse d.My health is excellent *This form includes questions from the SF-36TM Health Survey. Reproduced with the permission of the Medical Outcomes Trust, Copyright 1992.2000 IKDC SUBJECTIVE KNEE EVALUATION FORMYour Full Name_Todays D

22、ate: _/_/_ Date of Injury: _/_/_ Day Month Year Day Month YearSYMPTOMS*:*Grade symptoms at the highest activity level at which you think you could function without significant symptoms, even if you are not actually performing activities at this level.1.What is the highest level of activity that you

23、can perform without significant knee pain? Very strenuous activities like jumping or pivoting as in basketball or soccer Strenuous activities like heavy physical work, skiing or tennis Moderate activities like moderate physical work, running or jogging Light activities like walking, housework or yar

24、d work Unable to perform any of the above activities due to knee pain2.During the past 4 weeks, or since your injury, how often have you had pain? 0 1 2 3 4 5 6 7 8 9 10Never Constant3.If you have pain, how severe is it? 0 1 2 3 4 5 6 7 8 9 10No pain Worst pain imaginable4.During the past 4 weeks, o

25、r since your injury, how stiff or swollen was your knee? Not at all Mildly Moderately Very Extremely5.What is the highest level of activity you can perform without significant swelling in your knee? Very strenuous activities like jumping or pivoting as in basketball or soccer Strenuous activities li

26、ke heavy physical work, skiing or tennis Moderate activities like moderate physical work, running or jogging Light activities like walking, housework, or yard work Unable to perform any of the above activities due to knee swelling6.During the past 4 weeks, or since your injury, did your knee lock or

27、 catch? Yes No7.What is the highest level of activity you can perform without significant giving way in your knee? Very strenuous activities like jumping or pivoting as in basketball or soccer Strenuous activities like heavy physical work, skiing or tennis Moderate activities like moderate physical

28、work, running or jogging Light activities like walking, housework or yard work Unable to perform any of the above activities due to giving way of the kneePage 2 2000 IKDC SUBJECTIVE KNEE EVALUATION FORMSPORTS ACTIVITIES:8.What is the highest level of activity you can participate in on a regular basis? Very strenuous activities like jumping or