IKDC KNEE FORM 1999

 

The entire IKDC form, including a modems compatible demographic form and current health assessment, subjective knee evaluation form, knee history form, surgical documentation form, and IKDC knee examination form may be used as separate modules. Researchers who want to remain modems compatible and use benchmarking data are required to complete the demographic form and current health assessment. The knee history form and surgical documentation form are provided for convenience. All researchers are required to complete the IKDC subjective knee evaluation and knee examination forms. Scoring of the subjective form is performed by adding the scores of each question on the form. Instructions for the examination module are provided on the back of the form.

 

 

TABLE OF CONTENTS

 

1.   Modems Compatible Demographic Form

 

2.   Current Health Assessment

 

3.   Subjective Knee Evaluation Form

 

4.   Knee History Form

 

5.   Surgical Documentation Form

6.    Knee Examination Form

7.   Scoring Instructions

8. Instructions for the IKDC Knee Examination form


 


MODEMS COMPATIBLE DEMOGRAPHIC FORM

(OPTIONAL)

 

Your Last Name______________

 

Your Birth date _________________

 

Your Social Security Number______________

Gender Male______    Female_____

 

Occupation

 


Today’s Date

_______I                                         I______


 

The following is a list of common health problems. Please indicate yes or no in the first column, 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 the problem?Do you receive treatment for it?Does it limit your activities?

                                             Yes No                      Yes No                                      Yes No

Heart 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

 

Rheumatoid arthritis

 

Back pain

Lyme Disease

 

Current Health Assessment

 

 

1.   In general, would you say your health is: 
Excellent  Very Good  Good  Fair  Poor

 

2.   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 ago

3. The following items are about activities you might do during a typical day. Does your health now limit you in any of these activities?

 If so, how much?
                                                                                          Yes, Limited     Yes, Limited   No, Not Limited
                                                                                                     A Lot       A Little              At All

            a.   Vigorous activities, such as running, lifting
                  heavy objects, participating in strenuous sports                                 

b.  Moderate activities, such as moving a table,

                  pushing a vacuum cleaner, bowling, or playing golf?                         

           c.    Lifting or carrying groceries                                                                
           d.    Climbing several flight of stairs                                                       
           e.    Climbing one flight of stairs                                                          
           f.     Bending, kneeling or stooping                                     
           g.    Walking more than a mile                                            
           h.    Walking several blocks                                                
                  Walking one block                                                      
           i      Bathing or dressing yourself                                        

 

4.   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 your

       physical health?
                                                                                                       YES                    NO
          a.     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 work or other activities.     
          d.     Had difficulty performing the work or other activities
                  If or 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 anxious)?

                                                                                                                                   YES                     NO

            a.   Cut down on the amount of time you spent on                          

                  work or other activities
            b.   Accomplished less than you would like

c.      Didn’t do work or other activities as carefully as usual

 

 

6.  During the past 4 weeks, to what extent has your physical health or emotional problems interfered with your normal

social activities with family, friends, neighbors, or groups?

Not at all   slightly  moderately  quite a bit   extremely

 


7. How much bodily pain have you had during the past 4 weeks?

None   Very mild  Mild   Moderate   Severe  Very Severe

8. During the past 4 weeks, how did pain interfer with your normal work (including both work outside the home and housework)?

 Not at all  A little bit  Moderately  Quite a bit  Extremely

9.These questions are about how you feel and how things have been with you in the last 4 weeks. For each question, please give the one answer that comesmscomes closcomes closest to the way that you have been feeling. How much of the time during the past 4 weeks.

 

   All of the time Most of the time  A good bit of the time Some of the time A little of the time None of the time

 

 a.   Did you feel full of pep? 
 b.   Have you been very
                          nervous?                        
  c.   Have you felt calm and
                          peaceful?                       
  d.   Did 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?          

 

   

1 0.   During the past 4 weeks, how much10. During the past 4 weeks, how much of the time has your physical health or emotional problems interfered with your social activities (like visiting with friends, relatives, etc.?

 

AII of the time Most of the time  Some of the time A little of the time None of the time



 

11. How TRUE or FALSE is each of the following statements for you?

 

Definitely    Mostly  Don’t     Mostly

True       True     Know     False

 

a.   I seem to get sick a little easier than other people

h.   I am as healthy as anybody I know

c.   I expect my health to get worse

d.   My health is excellent

 

 

 

1.  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:        _________feet __________ 3.   Your weight _______

 

4.   Your race (indicate all that apply)  White Asian or Pacific Islander Black or African American Hispanic Native American Indian Other

 

5.   How much school have you completed? Less than high school Graduated from high school Some college  Graduated from college Postgraduate school or degree

 

6.   Activity level

 

 Are you a high competitive sports person

 

Are you well-trained and frequently sporting

 

Sporting sometimes

 

Non-sporting

 

IKDC SUBJECTIVE KNEE EVALUATION FORM

 

 

 

Your Full Name

Today’s Date                /            I                    Date of Injury         /             /

 

SYMPTOMS:

 

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

 Strenuous activities like 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 pain

2. During the past 4 weeks, or since      your injury, how often have you had pain?
                           o        1         2         3        4         5        6     7     8     9      10
                  Never                                                                                         Constant
3. If you have pain, how severe is it?
                           o        1         2         3        4         5        7    8         9       10

       No pain                                                                                                    Worst pain

                                                                                                                                       imaginble

4.   During the past 4 weeks, or since your injury, how stiff or swollen was your knee?

       Not at all        Mildly            Moderately               Very                  Extremely

 

5.   What is the highest level of activity you can perform without significant swelling in your knee?

Very strenuous 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 yard work

Unable to perform any of the above activities due to knee swelling

 

6.   During the past 4 weeks, or since your injury, did your knee lock or catch?

                       Yes                 No

 

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

Strenuous activities like heavy physical work, skiing or tennis

Moderate activities like moderate physical work, running or jogging

Light activities like walking, housework or yard work