PATIENT WOMAC ASSESSMENT FORM

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 perform 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.

Name

First Name

Last Name

Date of Birth

YYYY

Do you suffer from Knee Pain?

Yes

Have you been diagnosed with Osteoarthritis?

Yes

Do you suffer from Knee Stiffness?

Yes

Does your knee pain or stiffness keep you from preforming Daily Life Activities such as walking upstairs, getting out of a car, taking off your socks?

Yes