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Questionnaire
問卷
問卷
1.
[Injury and Surgical History] Mechanism of ACL Injury (How did the injury occur?)
--- Please Select ---
Twisting injury
Sudden stop/change of direction
Landing from a jump
Direct impact/contact
Other
2.
[Injury and Surgical History] Were there any concurrent ligament or meniscus injuries diagnosed?
No
Yes. Meniscus injury (medial)
Yes. Meniscus injury (lateral)
Yes. MCL injury
Yes. LCL injury
Yes. PCL injury
Other
3.
[Injury and Surgical History] Did you undergo any concurrent surgeries at the time of ACL surgery?
No
Yes. Meniscal repair
Yes. Meniscectomy
Yes. Other ligament repair/reconstruction
Yes. Cartilage procedures (e.g., microfracture)
Yes. Other
4.
[Medical and Physical Assessment] Have you received clearance from your surgeon to participate in an exercise program?
Yes
No
5.
[Medical and Physical Assessment] Please rate your current pain level (0 = no pain, 10 = extreme pain): At rest: __/10
--- Please Select ---
0
1
2
3
4
5
6
7
8
9
10
6.
[Medical and Physical Assessment] Please rate your current pain level (0 = no pain, 10 = extreme pain): During movement: __ /10
--- Please Select ---
0
1
2
3
4
5
6
7
8
9
10
7.
[Medical and Physical Assessment] Do you experience swelling around your knee?
Yes. Mild
Yes. Moderate
Yes. Severe
No.
8.
[Medical and Physical Assessment] Are you currently using any assistive devices (crutches, braces)?
Crutches
Brace
None
9.
[Medical and Physical Assessment] Current Knee Range of Motion in Flexion (Fill in NA if unknown)
10.
[Medical and Physical Assessment] Current Knee Range of Motion in Extension (Fill in NA if unknown)
11.
[Functional Status] Are you able to walk comfortably without support?
No
Yes.
12.
[Functional Status] Can you comfortably climb stairs?
Yes
No
13.
[Functional Status] Have you started any form of rehabilitation or physiotherapy after your surgery?
Yes
No
14.
[Goals and Preferences] What are your primary goals for participating in the exercise program? (Select all that apply)
Reduce pain
Improve range of motion
Enhance muscle strength
Improve stability/balance
Return to sports or high-level activities
Improve overall function and daily activities
Other
15.
[Goals and Preferences] How many days per week are you able to attend the exercise program?
1–2 days
3–4 days
>5 days
16.
[Health and Safety] Do you have any other medical conditions or injuries that we should be aware of? (If no, please fill in NA)
17.
[Health and Safety Screening] Are you currently taking any medications? (If no, please fill NA)
Qty
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