IKDC SUBJECTIVE KNEE

EVALUATION FORM
Patient Name: ___________________________________ Date of the Injury: __________________________________
Date: ____________________________________________

SYMPTOMS
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 CAN PERFORM WITHOUT SIGNIFICANT KNEE PAIN?

Very strenuous activities like jumping or pivoting as in basketball or soccer (4)

Strenuous activities like heavy physical work, skiing or tennis (3)
Moderate activities like moderate physical work, running or jogging (2)
Light activities like walking, housework or yard work (1)
Unable to perform any of the above activities due to knee pain (0)

2 - DURING THE PAST 4 WEEKS, OR SINCE YOUR INJURY, HOW OFTEN HAVE YOU HAD PAIN?

never constant
10 9 8 7 6 5 4 3 2 1 0

3 - IF YOU HAVE PAIN, HOW SEVERE IS IT?

no worst pain
pain 10 9 8 7 6 5 4 3 2 1 0 imaginable

4 - DURING THE PAST 4 WEEKS, OR SINCE YOUR INJURY, HOW STIFF OR SWOLLEN WAS YOUR KNEE?

Not at all (4)

Mildly (3)
Moderately (2)
Very (1)
Extremely (0)

5 - 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 (4)

Strenuous activities like heavy physical work, skiing or tennis (3)
Moderate activities like moderate physical work, running or jogging (2)
Light activities like walking, housework, or yard work (1)
Unable to perform any of the above activities due to knee swelling (0)

6 - DURING THE PAST 4 WEEKS, OR SINCE YOUR INJURY, DID YOUR KNEE LOCK OR CATCH?

yes (0) No (1)

7 - 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 (4)

Strenuous activities like heavy physical work, skiing or tennis (3)
Moderate activities like moderate physical work, running or jogging (2)
Light activities like walking, housework, or yard work (1)
Unable to perform any of the above activities due to giving way (0)

SPORTS ACTIVITIES
8 - WHAT IS THE HIGHEST LEVEL OF ACTIVITY YOU CAN PERFORM ON A REGULAR BASIS?

Very strenuous activities like jumping or pivoting as in basketball or soccer (4)

Strenuous activities like heavy physical work, skiing or tennis (3)
Moderate activities like moderate physical work, running or jogging (2)
Light activities like walking, housework, or yard work (1)
Unable to perform any of the above activities (0)

9 - HOW DOES YOUR KNEE AFFECT YOUR ABILITY TO:

Not difficult Minimally Moderately Extremely Unable

at all difficult difficult difficult to do
a. Go up stairs (4) (3) (2) (1) (0)
b. Go down stairs (4) (3) (2) (1) (0)
c. Kneel on the front of your knee (4) (3) (2) (1) (0)
d. Squat (4) (3) (2) (1) (0)
e. Sit with your knee bent (4) (3) (2) (1) (0)
f. Rise from a chair (4) (3) (2) (1) (0)
g. Run straight ahead (4) (3) (2) (1) (0)
h. Jump and land on your involved leg (4) (3) (2) (1) (0)
i. Stop and start quickly (4) (3) (2) (1) (0)

FUNCTION
10 - HOW WOULD YOU RATE THE FUNCTION OF YOUR KNEE ON A SCALE OF 0 TO 10 WITH 10 BEING NORMAL,
EXCELLENT FUNCTION AND 0 BEING THE INABILITY TO PERFORM ANY OF YOUR USUAL DAILY ACTIVITIES
WHICH MAY INCLUDE SPORTS?

Function prior to your knee injury:

0 1 2 3 4 5 6 7 8 9 10
Couldn't perform No limitation in
daily activities daily activities

Current function of your knee:

0 1 2 3 4 5 6 7 8 9 10
Couldn't perform No limitation in
daily activities daily activities

MORE INFORMATION