Am i a candidate for joint REPLACEMENT?

To help your doctor decide if knee replacement surgery is for you, answer the questions below.

In general, your pain can be described as:

• Mild but does not affect movement

• Moderate and some difficulty with movement

• Severe and great difficulty with movement

• Extremely severe and certain movements are impossible

Does your knee pain affect your sleep?

• Never

• Sometimes

• Mostly

• Every night

Are you able to perform your basic household functions?

• Yes with very little difficulty

• I cannot perform certain tasks

• I can only perform some tasks

• I am mostly dependent on others

Do you feel your knee is unstable or may give way?

• No

• Sometimes

• Often

• Always

While walking, how long does it take before you experience severe knee pain?

• More than half an hour

• 15-30 minutes

• 5-15 minutes

• Less than 5 minutes or instant pain with walking

Are you able to walk down a flight of stairs?

• Yes, with little difficulty

• Yes, with some difficulty

• Sometimes I can’t

• Most of the time I can’t

After sitting for a long time, describe the pain you experience on standing?

• Mild, with little difficulty getting up

• Severe, with great difficulty getting up

• Severe, with great difficulty getting up

• Extremely severe, requiring assistance to get up

Can you kneel down and get back up again?

• I can with no difficulty

• I can with some difficult

• I can but it’s very difficult

• Impossible

While driving, entering and exiting a car or using other forms of transport, your knee pain is described as:

• Mild

• Moderate

• Severe

• Extremely severe