Georgia Knee Institute

Osteoarthritis Index Questionnaire
First Name **
Last Name **
Email **
Phone Number *
Preferred Location **
Date of Birth **

MonthDayYear
The following questions ask about your feelings and experiences regarding the impact of knee pain and osteoarthritis symptoms on your life. Please consider each question as it relates to your experiences with knee pain during the previous 3 months. There are no right or wrong answers. Please be sure to answer every question by checking the most appropriate box. If the question does not apply to you, please check “none of the time” as your option.
Rate your pain when...
Walking*

NoneSlightModerateSevereExtreme
Climbing stairs*

NoneSlightModerateSevereExtreme
Sleeping at night*

NoneSlightModerateSevereExtreme
Resting*

NoneSlightModerateSevereExtreme
Standing*

NoneSlightModerateSevereExtreme
Rate your stiffness in the...
Morning*

NoneSlightModerateSevereExtreme
Evening*

NoneSlightModerateSevereExtreme
Rate your difficulty when...
Descending stairs*

NoneSlightModerateSevereExtreme
Ascending stairs*

NoneSlightModerateSevereExtreme
Rising from sitting*

NoneSlightModerateSevereExtreme
Standing*

NoneSlightModerateSevereExtreme
Bending to floor*

NoneSlightModerateSevereExtreme
Walking on even floor*

NoneSlightModerateSevereExtreme
Getting in/out of car*

NoneSlightModerateSevereExtreme
Going shopping*

NoneSlightModerateSevereExtreme
Putting on socks*

NoneSlightModerateSevereExtreme
Rising from bed*

NoneSlightModerateSevereExtreme
Taking off socks*

NoneSlightModerateSevereExtreme
Lying in bed*

NoneSlightModerateSevereExtreme
Getting in/out of bath*

NoneSlightModerateSevereExtreme
Sitting*

NoneSlightModerateSevereExtreme
Getting on/off toilet*

NoneSlightModerateSevereExtreme
Doing light domestic duties (cooking, dusting)*

NoneSlightModerateSevereExtreme
Doing heavy domestic duties (moving furniture)*

NoneSlightModerateSevereExtreme
LIINE LOCATION
Have you scheduled an appointment with us before? **
LIINE IS NEW
Phone Condition
Total Score
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