| 30947-6 | Date form completed | |
| 21112-8 | Birth date | |
| 8302-2 | Body height | |
| 29463-7 | Weight | |
| 46098-0 | Sex | |
| 20228-3 | Anatomic part Laterality | |
| 46463-6 | Race or ethnicity | |
| 67782-3 | Surgical operation date | |
| 97810-6 | Surgeon Provider | |
| 100160-1 | Knee replacement | |
| 100161-9 | Charnley Functional Classification | |
| 100162-7 | Alignment W Stand Knee XR | |
| 100163-5 | Knee med AndOr lat instab W full ext | |
| 100164-3 | Knee AP instability W 90 deg flex | |
| 100165-0 | Knee Qn | |
| 100166-8 | Flexion contracture range Knee | |
| 100167-6 | Extensor lag range Knee | |
| 100198-1 | Pre-op objective knee indicators score:Score:Pt:^Patient:Qn:Knee Society Score | |
| 100168-4 | Knee pain severity with level walking:Find:Pt:^Patient:Ord: | |
| 100169-2 | Knee pain severity with stairs or inclines:Find:Pt:^Patient:Ord: | |
| 100170-0 | Knee feels normal:Find:Pt:^Patient:Ord: | |
| 100199-9 | Pre-op symptoms score:Score:Pt:^Patient:Qn:Knee Society Score | |
| 100171-8 | Satisfaction with level of knee pain while sitting:Find:Pt:^Patient:Ord: | |
| 100172-6 | Satisfaction with level of knee pain while lying in bed:Find:Pt:^Patient:Ord: | |
| 100173-4 | Satisfaction with knee function while getting out of bed:Find:Pt:^Patient:Ord: | |
| 100174-2 | Satisfaction with knee function while performing light household duties:Find:Pt:^Patient:Ord: | |
| 100175-9 | Satisfaction with knee function while performing recreational activities:Find:Pt:^Patient:Ord: | |
| 100292-2 | Pre-op patient satisfaction score:Score:-:^Patient:Qn:Knee Society Score | |
| 100176-7 | Expect surgery to relieve pain:Find:Pt:^Patient:Ord: | |
| 100177-5 | Expect surgery will improve ability to perform activities of daily living:Find:Pt:^Patient:Ord: | |
| 100178-3 | Expect surgery will improve ability to perform leisure, recreational, or sports activities:Find:Pt:^Patient:Ord: | |
| 100200-5 | Pre-op patient expectations score:Score:Pt:^Patient:Qn:Knee Society Score | |
| 100179-1 | Walk without assistive mobility devices:Find:Pt:^Patient:Ord: | |
| 100180-9 | Assistive mobility devices used:Find:Pt:^Patient:Nom: | |
| 100181-7 | Assistive mobility devices used due to health condition:Find:Pt:^Patient:Ord: | |
| 100182-5 | Duration of standing before sitting due to knee discomfort:Time:Pt:^Patient:Ord: | |
| 100183-3 | Duration of walking before stopping due to knee discomfort:Time:Pt:^Patient:Ord: | |
| 100184-1 | How bothersome is knee when walking on an uneven surface:Find:Pt:^Patient:Ord: | |
| 100185-8 | How bothersome is knee when turning or pivoting leg:Find:Pt:^Patient:Ord: | |
| 100186-6 | How bothersome is knee when climbing up or down a flight of stairs:Find:Pt:^Patient:Ord: | |
| 100187-4 | How bothersome is knee when getting up from a low seat without armrests:Find:Pt:^Patient:Ord: | |
| 100188-2 | How bothersome is knee when getting into or out of a car:Find:Pt:^Patient:Ord: | |
| 100189-0 | How bothersome is knee when moving laterally:Find:Pt:^Patient:Ord: | |
| 100190-8 | How bothersome is knee when climbing a ladder or step stool:Find:Pt:^Patient:Ord: | |
| 100191-6 | How bothersome is knee when carrying a bag for one block:Find:Pt:^Patient:Ord: | |
| 100192-4 | How bothersome is knee when squatting:Find:Pt:^Patient:Ord: | |
| 100193-2 | How bothersome is knee when kneeling:Find:Pt:^Patient:Ord: | |
| 100194-0 | How bothersome is knee when running:Find:Pt:^Patient:Ord: | |
| 100201-3 | Pre-op functional activities score:Score:Pt:^Patient:Qn:Knee Society Score | |
| 73985-4 | Exercise activity | |
| 73985-4 | Exercise activity | |
| 73985-4 | Exercise activity | |
| 100197-3 | Exercise activity & pain severity panel:-:Pt:^Patient:-: | |
| 100197-3 | Exercise activity & pain severity panel:-:Pt:^Patient:-: | |
| 100197-3 | Exercise activity & pain severity panel:-:Pt:^Patient:-: | |
| 100202-1 | Pre-op discretionary knee activities score:Score:Pt:^Patient:Qn:Knee Society Score | |
| 100196-5 | Pre-op total score:Score:Pt:^Patient:Qn:Knee Society Score | |
| 100159-3 | Knee Society Score pre-op panel:-:Pt:^Patient:-:Knee Society Score | |