Patient Name Date Knee Outcome Survey Activities of 2026

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  1. Click ‘Get Form’ to open it in the editor.
  2. Begin by entering your name in the 'Patient Name' field. This personalizes the survey and ensures accurate record-keeping.
  3. Next, input the date in the 'Date' field. This helps track when the survey was completed.
  4. For the Knee Outcome Survey Activities of Daily Living Scale (ADLS), rate your physical function by selecting a score from 0 to 5 for each activity listed. Use the provided scale to reflect your current abilities.
  5. Once you have completed all ratings, calculate your total score and enter it in the 'Total Score' field. This percentage reflects your overall physical function.
  6. If you are a Medicare patient, complete the additional section by calculating your function and impairment percentages based on your total score.
  7. Finally, sign and date both the 'Patient Signature' and 'Therapist Signature' fields to validate the document.

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Score values range from 0 points to 5 points for each question in this survey. The total score for the KOS-ADL and KOS-SAS sections are achieved by summing the values assigned to each respective question, and then dividing by the total possible points and then multiplying that number by 100.
Scoring: The first column is scored 5 points for each item, followed in successive columns by scores of 4, 3, 2, 1, and 0 for the last column. The total points from all items are summed, then divided by 55 and multiplied by 100 for the SAS score.
The KOOS-12 impact scorer is calculated as an average of the three subscales [13]. A score of 100 indicates the best possible results and 0 the worst outcome.
The Lyshom Knee Scoring Scale is a patient-reported instrument that consists of subscales for pain, instability, locking, swelling, limp, stair climbing, squatting, and the need for support. Scores range from 0 (worse disability) to 100 (less disability). Original Literature: Lysholm, Jack, and Jan Gillquist.
KOOS questionnaire The WOMAC is used worldwide for elderly patients with knee OA [3]. The KOOS questionnaire evaluates the functional status and QoL of patients with any type of knee injury who are at increased risk of developing OA; i.e., patients with ACL injury, meniscus injury, or chondral injury.

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