KOOS - English
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Page 1 of 4
1.
Today's date
*
2.
Name (First and Last)
*
3.
Date of Birth
*
4.
What is your e-mail address?
This is only collected for the purpose of sending email reminders to you when it is time to re-take the survey.
5.
This survey must be completed prior to surgery and at intervals of 3 months, 6 months, 1 year, 2 years, and 5 years post surgery. Would you like an email reminder when it is time to complete the survey again?
Yes
No
6.
When are you taking this survey?
If you have not had your surgery yet, please choose "Prior to Surgery."
If you have had your surgery, please select the option that indicates
about
how long ago your surgery took place
Prior to Surgery
3 months post-surgery
6 months post-surgery
1 year post-surgery
2 years post-surgery
3 years post-surgery
5 years post-surgery
7.
Surgeon name:
-- None --
Auld, Merritt Kevin
Bruckner, James
Cannon, Christopher
Christal, Aric
Crutcher, James
Degan, Thomas
Downer, Philip
Falicov, Alexis
Flugstad, Daniel
Franklin, Jonathan
Holland, Lawrence
Hormel, Scott
King, Jason
Komenda, Gregory
Kuechle, David
Kvidera, Dennis
Leavitt, Shane
Lee, Frederick
Mandt, Peter
Nathe, Tyler
Peterson, Charles II
Pritchett, James
Ratcliffe, Steven
Roberts, Neil
Seidner, Todd
Toomey, Sean
Watt, Jay
Weil, Wayne
Williams, Paul
Wilson, William
Other/Unknown
If Other, please type in surgeon name
8.
What procedure are you having done?
If you are taking this survery post-surgery, which procedure did you have done?
-- None --
Total Knee Replacement
Partial Knee Replacement
Other
If Other, please type in procedure
9.
Which knee are you having replaced?
If you are taking this survey post-surgery, which knee did you have replaced?
-- None --
Right
Left
Both