Make Appointment - Health Link Wellness

First Name

Last Name

Date of Birth

Age

Sex

Male

Female

Other Contact

Timefram : Pre op

1-3 week

1-3 month

4-6 month

more than 12 month

App date

Side

Left

Right

Patient to complete. Tick (✔) one box for every question (during the past 4 weeks)

1. How would you describe the pain in your knee?

None

Very Mild

Mild

Moderate

Servere

2. How long can you walk (with or without stick) before the pain in your knee becomes severe?

No pain / more than 30 mins

16–30 mins

5–15 mins

Around the house only

Not at all / pain severe

3. After a meal (sat at a table), how painful is the knee to stand up?

Not at all painfull

Slightly painful

Modderately painful

Very painful

Unbearabal

4. Have you been troubled by pain from your knee in bed at night?

Not troubled at all

Only 1 or 2 nights

Some nights

Most nights

Every night

5. How much has pain from your knee interfered with your usual work (including housework)?

Not at all

A little bit

Moderately

Greatly

Totally

6. Could you walk down one flight of stairs?

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

7. Have you been limping when walking because of your knee?

Rarely /never

Sometimes, or just at first

Often, not just at fisrt

Most of the time

All of the time

9. Could you kneel down and get up again afterwards?

Yes, easily

Slightly painful

Moderately painful

Very painful

Unbearable / No, impossible

10. Have you had any trouble with washing and drying yourself (all over)?

Not trouble at all

Very little trouble

Moderate trouble

Extreme trouble

Impossible to do

11. Have you had any trouble getting in and out of a car or using public transport because of your knee?

Not trouble at all

Very little trouble

Moderate trouble

Extreme trouble

Impossible to do

12. Could you do the household shopping on your own?

Yes, easily

With little difficulty

With moderate difficulty

With extreme difficulty

No, impossible

Instructions : Please rate the activities in catezory according to the following scale of dificulty:

0 = None 1 = Slight 2 = Moderate 3 = Very 4 = Extremely

Pian

	None	Slight	Moderate	Very	Extremely
1. Walking
2. Stair climbing
3. Nocturnal
4. Rest
5. Weight bearing

Stiffness

	None	Slight	Moderate	Very	Extremely
1. Morning Stiffness
2. Stiffness occurring later in the day

Physical Function

	None	Slight	Moderate	Very	Extremely
1. Descending Stairs
2. Ascending stairs
3. Rising from sitting
4. Standing
5. Bending to floor
6. Walking on fiat surface
7. Getting in/out of car
8. Going shopping
9. Putting on socks
10. Lying in bed
11. Taking off socks
12. Rising from bed
13. Getting in/out bath
14. Sitting
15. Getting on/off toilet
16. Heavy domestic duties
17. Light domestic duties

Daily Living Ability Barthel ADL index

1. Feeding (Eating when the meal is prepared in front of you.)

0. Cannot scoop food into the mouth; someone has to feed.

1. Can scoop food by yourself but needs help, such as having someone prepare the food with a spoon or cut it into small pieces in advance.

2. Can scoop food and help yourself normally.

2. Grooming (Washing face, combing hairs, brushing tooth, and shaving within the last 24 to 28 hours.)

0. Need help

1. You can do it yourself (including those that you can do yourself if the equipment is prepared).

3. Transfer (Getting up and sitting up from bed, or moving from the bed to a chair)

0. Unable to sit (always falls over when sitting) or requires two people to lift you up.

1. Require significant assistance to sit, such as one strong or skilled person, or two ordinary people to support or lift you in order to sit.

2. Require some assistance, such as being instructed to follow or receiving slight support, or having someone to supervise for safety.

3. Can perform by yourself.

4. Toilet use

0. Cannot help yourself.

1. Can do some things by yourself (at least clean up after finishing) but needs help with certain tasks.

2. Can help yourself well (can get on and off the toilet independently, can clean up properly after finishing, and can put on clothes neatly).

5. Mobility (Movement within a room or house)

0. Can't move anywhere

1. Require a wheelchair to move around independently (without needing someone to push) and can navigate corners or doorways.

2. Walking or moving with assistance, such as being supported or told to do something, or requiring attention for safety.

3. Can walk or move on your own.

6. Dressing (Wearing clothes)

0. Need someone to help put on clothing; can hardly help yourself or can do so very little.

1. Can help yourself about 50%; the rest requires assistance from others.

2. Can help yourself well (including buttoning, zipping, or using adapted clothing that is suitable).

7. Stairs (Going up and down one floor)

0. Not possible

1. Need assistance

2. Can go up and down on your own (if a walking aid, such as a walker, is required, it must also be able to assist you in going up and down).

8. Bathing

0. Need assistance or need someone to help do it.

1. Can take a bath yourself.

9. Bowels (Retention of feces in the past week)

0. Cannot hold it or always requires an enema.

1. Sometimes cannot hold it (less than once a week).

2. Can hold it as usual.

10. Bladder (Urinary retention in the past week)

0. Cannot hold it, or requires a urinary catheter but cannot take care of it by yourself.

1. Sometimes cannot hold it (less than once a week).

2. Can hold it as usual.

Attract file

Choose File

Appointment Form

Health Link Clinic

Address

Opening hours

Services

Link us

Follow us