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Knee Progress Questionnaire
Please use this form to keep track of your progress
*Required
Email Address *
Name *
What week of the rehab program are you in? *
What level is your pain (0=no pain; 10=severe pain)? *
What is your Range of Motion for Flexion (bending the knee)? Please use a goniometer one handle on the thigh and one on the leg, measure the angle. Our goal is 110-120 degrees. *
What is your Range of Motion for Extension (straightening the knee)? Our goal is 0 degrees. (please answers with how many degrees you are from the knee being straight). Example 5 degrees would mean your knee is still bent about 5 degrees. *
Sit to Stand (timed). How many times can you get up from a seated position to standing without using your hands in 30 seconds?
What is your swelling? (Use the Tape Measure and measure in centimeters. Measurement of swelling needs to be taken from top of knee centered over knee cap) *
How many steps are you walking a day?
How long can you hold a Supine (lying down) Straight Leg Raise (seconds)? Try to bring the heel of your operated leg slightly higher than opposite foot. *
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