Formulaire KOOS

KOOS is the Knee injury and Osteoarthritis Outcome Score. It’s an international score used for the clinical evaluation of various knee pathologies.

You have seen Dr. Prost in consultation and he planned for you a program of intra-articular PRP injection of your knee: you must fill this questionnaire and submit it (by clicking on the box “send”) before being able to benefit your treatment for the osteoarthritis of your knee by PRP at the IMMR (Mediterranean Institute of Regenerative Medicine).

You will have to complete the same questionnaire in the 3rd month and the 6th month after your injection.

Thank you for taking the utmost care.

You must answer all the questions before you can send it.

Informations personnelles
Last name *
First name *
Email *
Date *
Injured knee *
Date of birth *
Size (en cm) *
Weight (en kg) *
BMI
Symptoms

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

Do you have swelling in your knee?
Do you feel grinding, hear clicking or any other type of noise when your knee moves?
Does your knee catch or hang up when moving?
Can you straighten your knee fully?
Can you bend your knee fully?
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.

How severe is your knee joint stiffness after first wakening in the morning?
How severe is your knee stiffness after sitting, lying or resting later in the day?
Pain
How often do you experience knee pain?

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

Twisting/pivoting on your knee
Straightening knee fully
Bending knee fully
Walking on a flat surface
Going up or down stairs
At night while in bed
Sitting or lying
Standing upright
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.

Descending stairs
Ascending stairs
Rising from sitting
Standing
Bending to floor/pick up an object
Walking on flat surface
Getting in/out of car
Going shopping
Putting on socks/stockings
Rising from bed
Taking off socks/stockings
Lying in bed (turning over, maintaining knee position)
Getting in/out of bath
Sitting
Getting on/off toilet
Heavy domestic duties (moving heavy boxes, scrubbing floors, etc)
Light domestic duties (cooking, dusting, etc)
Function, sports and recreational activities

The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your knee.

Squatting
Running
Jumping
Twisting/pivoting on your injured knee
Kneeling
Quality of Life
How often are you aware of your knee problem?
Have you modified your life style to avoid potentially damaging activities to your knee?
How much are you troubled with lack of confidence in your knee?
In general, how much difficulty do you have with your knee?
Please rate on the scale below the impact of pains
For 15 days on the knee on your quality of life
Please rate the pain below the following exercises on the scale below
Standing still with equal weight distribution on both legs
Standing upright on right leg only
Standing upright on left leg only
Please rate stability on the following scale after the exercises mentioned
Standing upright on the right leg only
Stationary standing on the left leg only
Pain observed on a walk test of 50 steps
The patient performs a walk of 50 steps on a flat surface without obstacle. Then he evaluates the pain using the EVA scale.
Overall Patient Assessment
Osteoarthritis Activity Last Week
Global Health Assessment Last Week
Please fill out all mandatory fields.
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KOOS