Patient name Date of visit Involved knee Date of original injury

right left

DIRECTIONS: KEY:
Scale Description
Using the KEY (at right), check 10 Normal knee, able to do strenuous work/sports with jumping, hard pivoting
the appropriate boxes on the 8 Able to do moderate work/sports with running, turning and twisting;
four scales below which indicate symptoms with strenuous work/sports
the highest level you can reach 6 Able to do light work/sports with no running, twisting or jumping;
WITHOUT having symptoms. symptoms with moderate work/sports
4 Able to do activities of daily living alone; symptoms with light work/sports
2 Moderate symptoms (frequent, limiting) with activities of daily living
0 Severe symptoms (constant, not relieved) with activities of daily living

1. PAIN ______/ 10

10 8 6 4 2 0

2. SWELLING (actual fluid in the knee; obvious puffiness) ______/ 10

10 8 6 4 2 0

3. PARTIAL GIVING-WAY (partial knee collapse, no fall to the ground) ______/ 10

10 8 6 4 2 0

4. FULL GIVING-WAY (knee collapse occurs with actual falling to the ground) ______/ 10
10 8 6 4 2 0

Location of pain inner side outer side front / kneecap back of knee all over
Type of pain sharp aching throbbing burning
Pain occurs on sitting standing stairs squatting running / jumping
Pain
Pain relieved by not by limiting by rest / pain not relieved
doing sports daily activities medications

Kneecap grinding? yes no Knee stiffness? yes no

Catching/ 1. Check one box: yes no My knee catches -- it does not move for a few seconds but works out.
Locking 2. Check one box: yes no My knee locks -- it does not move for five or more minutes at a time.

My job title is: Work status:

Work full time part time full duty light duty not working
Activity When I work, I experience:
no limitations mild limitations moderate limitations severe limitations

Exercise In my exercise program, I am:

Program making good progress slow progress, but better some problems with exercise exercise causes pain, problems doesn't apply

Follow-up Following my last visit, I am:

Progress making good progress slow progress, but better staying the same symptoms worse doesn't apply

Rate the overall condition of your knee at the present time. Circle one number below.
1 2 3 4 5 6 7 8 9 10
poor fair good normal
Patient
poor -- I have significant limitations that affect activities of daily living.
Grade fair -- I have moderate limitations that affect activities of daily living, no sports possible.
good -- I have some limitations with sports but I can participate; I compensate.
normal/excellent -- I am able to do whatever I wish (any sport) with no problems.

Average Pain (x2) ________ + swelling ________ + partial giving way________ + full giving way________ Subtotal = ________ = ________
5

SYMPTOM RATING FORM CINCINNATI KNEE RATING SYSTEM F02

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