Detailed questionnaire used to evaluate how knee pain and mobility issues affect a patient's ability to perform daily tasks.

Based on the image you provided, this is a Sapphire Outcome Survey designed to assess how various symptoms and physical limitations affect a person's daily activity level. The survey is divided into two main sections:

1. Symptoms Affecting Daily Activity Level
2. How Your Limitations Affect Your Ability to Do Specific Activities

The instructions ask you to circle one number per row for each section, indicating the degree to which each symptom or limitation affects your daily activity.

---

Section 1: Symptoms Affecting Daily Activity Level

This section asks you to rate how much each listed symptom (like pain, swelling, etc.) affects your ability to do daily activities *right now*. You circle a number from 0 to 5 for each symptom.

* 0 = Never have it (The symptom does not occur)
* 1 = Have, but does not affect activity (You have the symptom, but it doesn't interfere with what you do)
* 2 = Affects activity slightly (It causes minor interference)
* 3 = Affects activity moderately (It causes noticeable interference)
* 4 = Affects activity severely (It significantly interferes with your activities)
* 5 = Prevents me from all daily activity (The symptom completely stops you from doing anything)

Example Ratings (for illustration only - you must fill based on your own experience):

| Symptom/Condition | Rating |
| :------------------------- | :----- |
| Pain | 3 |
| Swelling or Stiffness | 2 |
| Clicking or grinding | 1 |
| Locking or catching | 4 |
| Buckling or giving way | 3 |
| Loss of range of motion | 2 |
| Limping | 3 |

*(Note: The image shows sample ratings already filled in. These are likely examples or pre-filled for demonstration. You should replace them with your own ratings.)*

---

Section 2: How Your Limitations Affect Your Ability to Do Specific Activities

This section asks you to rate how difficult it is for you to perform specific physical activities due to your condition. You circle one number per activity, ranging from 0 to 5.

* 0 = Not difficult at all (You can do it easily)
* 1 = Slightly difficult (A little effort required)
* 2 = Somewhat difficult (Moderate effort required)
* 3 = Fairly difficult (Significant effort required)
* 4 = Very difficult (Extremely hard to do)
* 5 = Unable to do (You cannot perform the activity)

Example Ratings (for illustration only - you must fill based on your own experience):

| Activity | Rating |
| :--------------------------- | :----- |
| Walk | 2 |
| Go upstairs | 4 |
| Go downstairs | 3 |
| Sit | 1 |
| Stand | 2 |
| Bend at the waist | 3 |
| Rise from a chair | 3 |
| Squat | 4 |
| Sit with your knees bent | 2 |
| Get in/out of car | 3 |

*(Again, the image shows sample ratings. Replace these with your personal assessment.)*

---

Scoring and Interpretation

At the bottom, there is a section for calculating scores and recording demographic information.

* Office Use Only: Score: This is calculated by summing all the numbers you circled in both sections.
* Section 1 has 7 items.
* Section 2 has 10 items.
* Total possible score: 17 items x 5 points maximum = 85 points.
* Lower scores indicate less impact on daily life. Higher scores indicate greater disability or limitation.

* NRS-11 Scale: This refers to the Numerical Rating Scale (0-10) for pain intensity, which might be assessed separately.
* Number of PT Sessions: Records how many physical therapy sessions the patient has had.
* Gender, M/F, Age: Basic demographic data.
* PT Initials: Physical therapist's initials for record-keeping.

---

Summary of How to Complete the Survey

1. Read the Instructions Carefully: Understand that you need to rate each item based on your *current* experience.
2. Section 1 (Symptoms): For each symptom, circle the number (0-5) that best describes how much it affects your daily activities *right now*.
3. Section 2 (Activities): For each activity, circle the number (0-5) that best describes how difficult it is for you to perform that activity *due to your condition*.
4. Calculate Total Score: Add up all the numbers you circled. This total score will help your healthcare provider understand the overall impact of your condition on your daily life.
5. Provide Demographic Info: Fill in gender, age, and any other requested information.
6. Return to Provider: Give the completed form to your doctor or physical therapist for evaluation.

This survey is a valuable tool for tracking progress over time (e.g., before and after treatment) and for guiding treatment plans based on the patient's self-reported functional limitations.