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Knee Pain Intake Form
Name
Social Security #
Date
Date of Birth
Age
Sex
Martial Status
Number of Children
Address
City
State
Zip Code
Phone
Email
Spouse Name
Spouse Phone
Your Occupation
Retired
Select One
Yes
No
Current / Previous Work: Clerical
Select One
Yes
No
Current / Previous Work: Light Labor
Select One
Yes
No
Current / Previous Work: Moderate Labor
Select One
Yes
No
Current / Previous Work: Heavy Labor
Select One
Yes
No
Emergency Contact Name
Emergency Contact Phone
Tell Us About Your Past Health
Please check all that apply
Lower Back Pain
Leg or Foot Pain / Numbness
Spinal Fractures
Spinal Stenosis
Spinal Arthritis
Sciatica
Neck Pain
Herniated Disc
Diabetes
Hand Problems
Neuropathy
Heart Attack
Heart Problems
High / Low Blood Pressure
Vascular Leg Problems
Stroke
High Cholesterol
Vascular Surgery
Shingles
Knee Surgery
Kidney issues or Dialysis
Gout
Hip Surgery
Leg Fractures
Joint Replacement
Foot Surgery
PLEASE LIST ANY MEDICATION AND/OR VITAMINS YOU ARE CURRENTLY TAKING OR ATTACH MED LIST:
PLEASE LIST BELOW ANY SERIOUS MEDICAL CONDITIONS YOU HAVE HAD:
Name of Your Primary Care Physician
May We Contact Them With Updates Regarding Your Treatment?
Select One
Yes
No
Please List Below Any Back, Knee, or Leg Surgeries You've Had?
Have You Had an EMC Performed on Your Legs/Feet?
Select One
Yes
No
If so, when?
Do You Exercise Regularly?
Select One
Yes
No
What exercise?
Are Your Symptoms Worse at Night?
Select One
Yes
No
Around What Time?
Present Health Conditions
What Kind of Problem(s) Are You Having?
On A Scale, How Would You Rate Your Symptoms (10 Is The Worst)
When did this begin?
What makes it better?
What makes it worse?
How Would You Describe Your Symptoms?
Stabbing
Sharp
Stings
Electric-Shocks
Ache
Cold
Numbness
Tingling
Tiredness
Swelling
Cramping
Burning
Is This Condition Interfering With Any of the Following?
Sleep
Walking
Work
Standing
Daily Activities
Chores
How Would You Describe Your Average Knee Pain Over the Past Week?
1 - No Pain
2
3
4
5
6
7
8
9
10 - Worst Possible Pain
Please Indicate What You Consider to be an Acceptable Level of Pain After Completion of the Treatment, If You Have to Accept Some Pain?
1 - No Pain
2
3
4
5
6
7
8
9
10 - Worst Possible Pain
Which of the Following is True for Your Condition:
Select One
It's getting better on its own
It's staying the same
t's getting worse as time goes by
List any Daytime Activities (You Used to be Able to Do When You Were Feeling Better) That Are Now Limited:
m List the Three Main "Health Coals" That You Would Like to Accomplish:
Walking Scale Questionnaire
These questions ask about limitations to your walking due to knee pain during the past 2 weeks. For each statement please select the one number that best describes your degree of limitation.
In the past 2 weeks, how much has your knee pain...
(1 - Not At All / 2 - A Little / 3 - Moderately / 4 - Quite a bit / 5 - Extremely
Limited your ability to walk?
Select One
1
2
3
4
5
Limited your ability to run?
Select One
1
2
3
4
5
Limited your ability to climb up or down stairs?
Select One
1
2
3
4
5
Made standing when doing things more difficult?
Select One
1
2
3
4
5
Limited your balance when standing or walking?
Select One
1
2
3
4
5
Limited how far you are able to walk?
Select One
1
2
3
4
5
Increased the effort needed for you to walk?
Select One
1
2
3
4
5
Made it necessary for you to use support when walking indoors (e.G. Holding on to furniture, using a cane, etc.)?
Select One
1
2
3
4
5
Made it necessary for you to use support when walking outdoors (e.G. Using a cane or walker, etc.)?
Select One
1
2
3
4
5
Slowed down your walking?
Select One
1
2
3
4
5
Affected how smoothly you walk?
Select One
1
2
3
4
5
Made you concentrate on your walking?
Select One
1
2
3
4
5
Knee Pain Program Qualification Questionnaire
Do you experience knee pain?
Select One
Right
Left
Both
Do you experience knee pain at rest?
Select One
Yes
No
Do you have knee osteoarthritis confirmed by imaging?
Select One
Yes
No
Unsure
Has your knee pain interfered with activities (such as walking, going up/down stairs and/or standing) for at least six months?
Select One
Yes
No
Do you have morning knee stiffness lasting 30 minutes or less?
Select One
Yes
No
Do you experience a grinding sensation with knee movement?
Select One
Yes
No
Have you tried pain and/or anti-inflammatory medications (i.e.: Tylenol, Aspirin, Advil, or capsaicin cream) for at least three months without gaining long-term relief?
Select One
Yes
No
Have you attempted physical therapy to the affected knee or participated in a personal exercise program without long-term relief?
Select One
Yes
No
Have you attempted to lose weight to help with your knee pain?
Select One
Yes
No
Have you used a knee brace without long-term relief?
Select One
Yes
No
Has your doctor ever drained excess fluid from the affected knee(s)?
Select One
Yes
No
Have you tried steroid/cortisone injection(s) to the knee without long-term relief?
Select One
Yes
No
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