Patient Name Date Knee Outcome Survey Activities of 2026

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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