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Date of completion

WOMAC Score

Patient's name (or ref
Clinician's name (or ref)
Patient's d.o.b
 

INSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to do your usual activities.

Answer every question by ticking the appropriate box. If you are unsure about how to answer a question, please give the best answer you can.
 

Symptoms - These questions should be answered thinking of your knee symptoms during the last week.

S1. Do you have swelling in your knee?
Never Rarely Sometimes Often Always
 

S2. Do you feel grinding, hear clicking or any other type of noise when your knee moves?

Never Rarely Sometimes Often Always

S3. Does your knee catch or hang up when moving?

Never Rarely Sometimes Often Always

S4. Can you straighten your knee fully?

Never Rarely Sometimes Often Always

S5. Can you bend your knee fully?

Never Rarely Sometimes Often Always

Stiffness - The following questions concern the amount of joint stiffness you have experienced during the last week in your knee. Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint.

S6. How severe is your knee joint stiffness after first wakening in the morning?

None Mild Moderate Severe Extreme

S7. How severe is your knee stiffness after sitting, lying or resting later in the day?

None Mild Moderate Severe Extreme
 

Pain1

P1. How often do you experience knee pain?

Never Monthly Weekly Daily Always
 

What amount of knee pain have you experienced the last week during the following activities?

P2. Twisting/pivoting on your knee
None Mild Moderate Severe Extreme
 

P3. Straightening knee fully
None Mild Moderate Severe Extreme
 

P4. Bending knee fully

None Mild Moderate Severe Extreme
 

P5. Walking on flat surface

None Mild Moderate Severe Extreme
 

P6. Going up or down stairs

None Mild Moderate Severe Extreme
 

P7. At night while in bed

None Mild Moderate Severe Extreme
 

P8. Sitting or lying

None
Mild Moderate Severe Extreme
 

P9. Standing upright

None Mild Moderate Severe Extreme
 

Function, daily living - The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee.

Al. Descending stairs

None Mild Moderate Severe Extreme
 

A2. Ascending stairs

None Mild Moderate Severe Extreme
 

For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee.

A3. Rising from sitting

None Mild Moderate Severe Extreme
 

A4. Standing

None Mild Moderate Severe Extreme
 

A5. Bending to floor/pick up an object

None Mild Moderate Severe Extreme
 

A6. Walking on flat surface

None Mild Moderate Severe Extreme
 

A7. Getting in/out of car

None Mild Moderate Severe Extreme
 

A8. Going shopping

None Mild Moderate Severe Extreme
 

A9. Putting on socks/stockings

None Mild Moderate Severe Extreme
 

A10. Rising from bed

None Mild Moderate Severe Extreme
 

A11. Taking off socks/stockings

None Mild Moderate Severe Extreme
 

A12. Lying in bed (turning over, maintaining knee position)

None Mild Moderate Severe Extreme
 

A13. Getting in/out of bath

None Mild Moderate Severe Extreme
 

A14. Sitting

None Mild Moderate Severe Extreme
 

A15. Getting on/off toilet

None Mild Moderate Severe Extreme
 
For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee

A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)

Never Rarely Sometimes Often Always
 

A17. Light domestic duties (cooking, dusting, etc)

Never Rarely Sometimes Often Always

Thank you very much for completing all the questions in this questionnaire.

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The Womac score is

Reference for Score: Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD. Knee Injury and Osteoarthritis Outcome Score (KOOS)--development of a self-administered outcome measure. J Orthop Sports Phys Ther. 1998 Aug;28(2):88-96. Link