Pre-Consultation Survey

Participant pre-consultation survey
Age (years) __________________________
Living arrangements
o Live alone
o Live with partner
o Live with others
Are you employed?
o Yes
o No
Do you experience pain in any parts of your body other than your knees?
o Yes
o No
Do you have any other major health problems?
________________________________________________________________
________________________________________________________________
What is your height? (metres)
________________________________________________________________
What is your current weight? (kilograms)
________________________________________________________________
1|PEAK Reproduced with permission from the CENTRE FOR HEALTH,

EXERCISE AND SPORTS MEDICINE – The University of Melbourne
ABOUT YOUR KNEE PROBLEMS:
Which knee do you experience pain in?
o Right
o Left
o Both
How long have you been experiencing knee pain?
________________________________________________________________
What do you do to ease your knee pain?
________________________________________________________________
________________________________________________________________
________________________________________________________________
Is there anything in particular that aggravates your knee pain?
________________________________________________________________
________________________________________________________________
________________________________________________________________
What treatments for your knee pain have you tried in the past? (e.g. medicines, injection, heat pad,
creams, physiotherapy)
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Did any of these treatments help your knee problems?
________________________________________________________________
________________________________________________________________
________________________________________________________________
EXERCISE & PHYSICAL ACTIVITY
Have you ever undertaken a muscle strengthening exercise program to help manage your knee
problems?
o Yes
o No
Do you currently participate in any exercise, sport or physical activities?
o Yes
o No
If yes, please describe what you currently do, and how often:
________________________________________________________________
________________________________________________________________
________________________________________________________________
How would you rate your general physical activity on a typical day? overall activity levels?
o Sedentary
o Light physical activity
o Moderate
o Vigorous
Have you ever used a wearable physical activity monitor or step counter (Fitbit, Garmin, pedometer)
before?
o Yes
o No

HOW YOUR KNEE PROBLEMS AFFECT YOU
What is the worst thing about having knee problems for you?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Is there anything that you can't do because of your knee problems?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________

Pain level: Choose the number which indicates the average amount of pain felt over the PAST WEEK
in your study knee.
o 0 (No pain)
o1
o2
o3
o4
o5
o6
o7
o8
o9
o 10 (worst pain possible)
How much difficulty do you have walking around inside the house?
o None
o A little
o Moderate
o A lot
o Can't do it

How much difficulty do you have walking for 10 mins outside the house?
o None
o A little
o Moderate
o A lot
o Can't do it
How much difficulty do you have standing up from the couch?
o None
o A little
o Moderate
o A lot
o Can't do it
How much difficulty do you have walking up stairs with no hand rail?
o None
o A little
o Moderate
o A lot
o Can't do it

How much difficulty do you have walking down stairs with no hand rail?
o None
o A little
o Moderate
o A lot
o Can't do it
YOUR PERSONAL GOALS
What are 2 things would you most like to be able to do in 3 months time (if your knee problems were
improved)?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
What 2 things would you most like to be able to do in 1 year (if your knee problems were getting
better)?
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________


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Participant pre-consultation survey

Age (years) __________________________

What is your height? (metres)

What is your current weight? (kilograms)

1|PEAK Reproduced with permission from the CENTRE FOR HEALTH,

Which knee do you experience pain in?

What do you do to ease your knee pain?

Is there anything in particular that aggravates your knee pain?

Did any of these treatments help your knee problems?

3|PEAK Reproduced with permission from the CENTRE FOR HEALTH,

Is there anything that you can't do because of your knee problems?

4|PEAK Reproduced with permission from the CENTRE FOR HEALTH,

5|PEAK Reproduced with permission from the CENTRE FOR HEALTH,

6|PEAK Reproduced with permission from the CENTRE FOR HEALTH,

7|PEAK Reproduced with permission from the CENTRE FOR HEALTH,

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