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.

1. Do you have swelling in your knee?

Never Rarely Sometimes Often Always
 

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

Never Rarely Sometimes Often Always

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

Never Rarely Sometimes Often Always

4. Can you straighten your knee fully?

Never Rarely Sometimes Often Always

5. 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.

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

None Mild Moderate Severe Extreme

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

None Mild Moderate Severe Extreme
 

Pain1

1. 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?

2. Twisting/pivoting on your knee

None Mild Moderate Severe Extreme
 

3. Straightening knee fully

None Mild Moderate Severe Extreme
 

4. Bending knee fully

None Mild Moderate Severe Extreme
 

5. Walking on flat surface

None Mild Moderate Severe Extreme
 

6. Going up or down stairs

None Mild Moderate Severe Extreme
 

7. At night while in bed

None Mild Moderate Severe Extreme
 

8. Sitting or lying

None
Mild Moderate Severe Extreme
 

9. 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.

1. Descending stairs

None Mild Moderate Severe Extreme
 

2. 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.

3. Rising from sitting

None Mild Moderate Severe Extreme
 

4. Standing

None Mild Moderate Severe Extreme
 

5. Bending to floor/pick up an object

None Mild Moderate Severe Extreme
 

6. Walking on flat surface

None Mild Moderate Severe Extreme
 

7. Getting in/out of car

None Mild Moderate Severe Extreme
 

8. Going shopping

None Mild Moderate Severe Extreme
 

9. Putting on socks/stockings

None Mild Moderate Severe Extreme
 

10. Rising from bed

None Mild Moderate Severe Extreme
 

11. Taking off socks/stockings

None Mild Moderate Severe Extreme
 

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

None Mild Moderate Severe Extreme
 

13. Getting in/out of bath

None Mild Moderate Severe Extreme
 

14. Sitting

None Mild Moderate Severe Extreme
 

15. 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

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

Never Rarely Sometimes Often Always
 

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

Never Rarely Sometimes Often Always

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

To save this data please print or

 
Womac score is

Reference: Waddell C, Newton M, Henderson I, et al. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain. 1993; 52:157-168.

Fritz JM, George S. Identifying Psychosocial Variables in Patients With Acute Work-Related Low Back Pain: The Importance of Fear-Avoidance Beliefs. Phys Ther. 2002; 82(10): 973-983.

Lethem J, Slade PD, Troup JDG, Bendey G. Outline of a fear avoidance model of exaggerated pain perceptions, Behav Res Ther. 1983;21:401-408.

Williamson E. Fear Avoidance Behavior Questionnaire. Austrailian Journal of Physiotherapy. 2006; 52: 149.

Vlaeyen JWS, Kole-Snijders AMJ, Boeren RGB, van Eck H. Fear of movement/(re)injury in chronic low back pain and its relation to behavioral performance. Pain. 1995;62: 36, 272.