PASC Knee Scores (SANE/KOOS)
Please enter the date *
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Last Name
Your answer
First Name *
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Date of Birth *
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Treating Doctor *
Which knee was treated? *
If both knees were treated please fill out a separate survey for each knee.
Where you treated with PRP or Stem Cells or both? *
Knee SANE-F Score *
Enter a number for the current functional level of your knee. 100% is normal function, 0% is completely disabled
Your answer
Knee SANE-I Score
Enter a number for the % improvement in your knee compared to before treatment. 100% is completely better, 0% is no improvement
Your answer
The KOOS Knee Survey should take 10 minutes to fill out and has 5 Subsections (Symptoms, Pain, Function, Sports, Lifestyle)
Your answer
The following 5 questions refer to knee symptoms you have had in the past week.
Your answer
Do you have swelling in your knee? (S1)
Do you feel grinding, hear clicking or any other type of noise when your knee moves? (S2)
Does your knee catch or hang up when moving? (S3)
Can you straighten your knee fully? (S4)
Can you bend your knee fully? (S5)
How severe is your knee joint stiffness after first waking in the morning? (S6)
How severe is your knee stiffness after sitting, lying or resting later in the day? (S7)
KOOS Knee Symptom Section Scoring (For PASC Staff Use Only)
None=0; Mild=1; Moderate=2; Severe=3; Always/extreme=4 100- (TOTAL x 100)/28 = SCORE
Your answer
KOOS Symptom Score (For PASC Staff Use Only)
Your answer
The next 10 questions refer to any knee pain you have had in the last week.
Your answer
How often is your knee painful? (P1)
How much knee pain have you had in the last week twisting or pivoting on your knee? (P2)
How much knee pain have you had in the last week straightening the knee fully? (P3)
How much knee pain have you had in the last week bending the knee fully? (P4)
How much knee pain have you had in the last week walking on a flat surface? (P5)
How much knee pain have you had in the last week going up and down stairs? (P6)
How much knee pain have you had in the last week at night while in bed? (P7)
How much knee pain have you had in the last week sitting or lying? (P8)
How much knee pain have you had in the last week standing upright? (P9)
KOOS Knee Pain Scoring Section (for PASC Staff Only)
none=0; mild=1; moderate=2; severe=3; always/extreme=4 100 - (TOTAL x 100)/36 = SCORE
Your answer
KOOS Pain Score (for PASC Staff Only)
Your answer
The next 17 questions refer to your physical function and daily living in the last week.
Your answer
How much difficulty have you had descending stairs? (A1)
How much difficulty have you had ascending stairs? (A2)
How much difficulty have you had rising from sitting? (A3)
How much difficulty have you had standing? (A4)
How much difficulty have you had bending to the floor or picking up an object? (A5)
How much difficulty have you had walking on a flat surface? (A6)
How much difficulty have you had getting in and out of a car? (A7)
How much difficulty have you had going shopping ? (A8)
How much difficulty have you had putting on socks or stockings? (A9)
How much difficulty have you had rising from bed? (A10)
How much difficulty have you had taking off socks or stockings? (A11)
How much difficulty have you had lying in bed? (A12)
How much difficulty have you had getting in and out of the bath? (A13)
How much difficulty have you had sitting? (A14)
How much difficulty have you had getting on an off the toilet? (A15)
How much difficulty have you had with heavy domestic duties (moving heavy boxes, scrubbing floors, etc.)? (A16)
How much difficulty have you had with light domestic duties (cooking, dusting, etc.)? (A17)
KOOS Knee ADL Scoring Section (For PASC Staff)
none=0; mild=1; moderate=2; severe=3; always/extreme=4 100- (TOTAL x 100)/68 = SCORE
Your answer
KOOS ADL Score (For PASC Staff)
Your answer
The next 5 questions refer to your physical function in sports and recreational activities in last week.
Your answer
How much difficulty have you had with squatting? (SP1)
How much difficulty have you had with running? (SP2)
How much difficulty have you had with jumping? (SP3)
How much difficulty have you had with twisting or pivoting on your knee? (SP4)
How much difficulty have you had kneeling? (SP5)
KOOS Knee Sports/ Rec Scoring Section (For PASC Staff)
none=0; mild=1; moderate=2; severe=3; always/extreme=4 100- (TOTAL x 100)/20 = SCORE
Your answer
KOOS Sports/Rec Score (For PASC Staff)
Your answer
The next 4 questions refer to your quality of life in last week.
Your answer
How often are you aware of your knee problem? (Q1)
Have you modified your lifestyle to avoid potentially damaging activities to your knee? (Q2)
How much are you troubled with lack of confidence in your knee? (Q3)
In general how much difficulty do you have with your knee? (Q4)
KOOS Knee QOL Scoring Section (For PASC Staff)
none=0; mild=1; moderate=2; severe=3; always/extreme=4 100- (TOTAL x 100)/16 = SCORE
Your answer
KOOS QOL Score (For PASC Staff)
Your answer
KOOS Knee Overall Score (For PASC Staff)
Add all 5 sections and divide by 5. 100 is no disability, 0 is complete disability
Your answer
Thank you for completing the KOOS Knee Survey!
Your answer
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