Knee Replacement Pre-Op QPROM

Thank you for choosing Kinvara Private Hospital for your knee replacement. Please complete this short questionnaire (known as a Quality Patient-Reported Outcome Measure – QPROM).

The questionnaire should only be completed by patients who due to have knee replacement and will only take a few minutes.

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Date of birth
1. Is anyone helping you fill in this questionnaire?
2. What is your sex?
3. Which statement best describes your living arrangements?
4. For how long have you had problems with the knee on which you are about to have surgery?
5. Have you had a previous joint replacement on the knee on which you are about to have surgery?

During the past 4 weeks;

6. How would you describe the pain you usually have from your knee?
7. Have you had any trouble with washing and dressing yourself (all over) because of your knee?
8. Have you had any trouble getting in and out of a car or using public transport because of your knee?
9. For how long have you been able to walk before pain from your knee becomes severe?
10. After a meal (sat at a table), how painful has it been for you to stand up from a chair because of your knee?
11. Have you been limping when walking, because of the knee?
12. Could you kneel and get up again afterwards?
13. Have you been troubled by pain from your knee in bed at night?
14. How much has the pain from your knee interfered with your usual work (including housework)?
15. Have you felt that your knee might suddenly give way or let you down?
16. Could you do the household shopping on your own?

By placing a tick in one box in each group below, please indicate which statements best describe your own health state today.

17. Mobility
18. Self-care
19. Usual activities (e.g. work, study, housework, family)
20. Pain/discomfort
21. Anxiety/ Depression
22. In general, how would you rate your general health?
23. Have you been told by a doctor that you have any of the following? (Check all that apply)
24. Do you consider yourself to have a disability?