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Date of completion
Knee Society Score - Function    
Clinician's name (or ref) Patient's name (or ref)
 
Please answer the following questions.  
Part 2 - Function
Walking
Unlimited
>10 blocks
5-10 blocks
<5 blocks
Housebound
Unable

 

  
Stairs
Normal Up and down
Normal Up down with rail
Up and down with rail
Up with rail, down unable
Unable

 

  
Walking aids used
None used
Use of Cane/Walking stick deduct
Two Canes/sticks
Crutches or frame
Function Score (Knee Society Score) is (NB: consider a negative outcome as zero)

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Reference for score: Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989 Nov;(248):13-4. link to pubmed

Reference for Grading: Asif S , Choon DS . Midterm results of cemented Press Fit Condylar Sigma total knee arthroplasty system. J Orthop Surg (Hong Kong). 2005 Dec;13(3):280-4.