IKDC2000.doc

2000 IKDC KNEE FORMS  INTRODUCTION The entire IKDC form, which includes a MODEMSTM compatible demographic form, current health assessment form, subjective knee evaluation form, knee history form, surgical documentation form, and knee examination form, may be used as separate forms. Researchers who want to remain MODEMSTM compatible and use benchmarking data are required to complete the demographic form and current health assessment form. The knee history form and surgical documentation form are provided for convenience. All researchers are required to complete the subjective knee evaluation and knee examination form. Instructions for scoring the subjective knee evaluation form and the knee examination form are provided on the back of the forms. TABLE OF CONTENTS  Demographic Form Current Health Assessment Form Subjective Knee Evaluation Form Knee History Form Surgical Documentation Form Knee Examination Form  IKDC DEMOGRAPHIC FORM Your Full Name ______________________________________________________ Your Date of Birth _________/___________/___________ Day Month Year Your Social Security Number ____-___-_____ Your Gender: ( Male ( Female Occupation __________________________________________________________ Today’s Date _____________/___________/___________ Day Month Year The following is a list of common health problems. Please indicate “Yes” or “No” in the first column, and then skip to the next item. If you do have the problem, please indicate in the second column if you receive medications or some other type of treatment for the problem. In the last column, indicate if the problem limits any of your activities. Do you have Do you receive Does it limit the problem? treatment for it? your activities? Yes No Yes No Yes No Heart disease ( ( ( ( ( ( High blood pressure ( ( ( ( ( ( Asthma or pulmonary disease ( ( ( ( ( ( D