Date of Completion

PROBLEMS WITH YOUR KNEE
Clinician's name (or ref)
Patient's name (or ref)
Patient's d.o.b
INSTRUCTIONS Tick ( ) one box for every question.

1. During the past 4 weeks...

How would you describe the pain you usually have from your knee?
None
Very mild
Mild
Moderate
Severe

2. During the past 4 weeks...

Have you had any trouble with washing and drying yourself (all over) because of your knee?
No trouble at all
Very little trouble
Moderate trouble
Extreme difficulty
Impossible to do

3. During the past 4 weeks...

Have you had any trouble getting in and out of a car or using public transport because of your knee? (whichever you would tend to use)
No trouble at all
Very little trouble
Moderate trouble
Extreme trouble
Impossible to do

4. During the past 4 weeks...

For how long have you been able to walk before pain from your knee becomes severe? (with or without a stick)
No pain/More than 30 minutes
16 to 30 minutes
5 to 15 minutes
Around the house only
Not at all/pain severe when walking

5. During the past 4 weeks...

After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your knee?
Not at all painful
Slightly painful
Moderately painful
Very painful
Unbearable

6. During the past 4 weeks...

Have you been limping when walking, because of your knee?
Rarely/ never
Sometimes, or just at first
Often, not just at first
Most of the time
All of the time

7. During the past 4 weeks...

Could you kneel down and get up again afterwards?
Yes, easily
With little difficulty
With moderate difficulty
With extreme difficulty
No, impossible

8. During the past 4 weeks...

Have you been troubled by pain from your knee in bed at night?
No nights
Only 1 or 2 nights
Some nights
Most nights
Every time

9. During the past 4 weeks...

How much has pain from your knee interfered with your usual work (including housework)?
Not at all
A little bit
Moderatety
Greatly
Totally

10. During the past 4 weeks...

Have you felt that your knee might suddenly 'give way' or let you down?
Rarely/ never
Sometimes, or just at first
Often, not just at first
Most of the time
All of the time

11. During the past 4 weeks...

Could you do the household shopping on your own?
Yes, easily
With little difficulty
With mode rate difficulty
With extreme difficulty
No, impossible

12. During the past 4 weeks...

Could you walk down one flight of stairs?
Yes, easily
With little difficulty
With mode rate difficulty
With extreme difficulty
No, impossible

Finally, please check back that you have answered each question. Thank you very much.

PROBLEMS WITH YOUR KNEE Score

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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.