Name
*
First Name
Last Name
Have you experienced any knee pain recently?
If yes, are you having pain in the right knee?
If yes, are you having pain in the left knee?
Do you experience pain in both knees at times?
Have you had any x-rays or MRIs done on your knees?
If yes,where
When?
-
Month
-
Day
Year
Date
Is your knee pain a result of an accident or injury that you incurred?
Have you ever had any knee surgeries?
If yes, when was your last surgery:
Have you ever been diagnosed with arthritis of the knees or any type of osteoarthritis?
Have you ever had any knee injections?
If yes, when was your last injection and by whom?
Does your current knee pain affect your quality of life? For example, does it prevent you from attending certain events or engaging in any physical activity?
Please explain
Have you had any recent falls?
When
How many falls have you experienced within the last 6 months?
Are you experiencing any numbness, tingling, or burning sensation with the knee pain?
Explain
Do you currently use a cane or other device to help you walk?
If so, what do you use
Have you attempted to lose weight because of the pain?
If you have lost weight recently, how much have you lost and has it helped to improve your pain symptoms?
Amount of weight lost
Have you ever experienced any buckling of the knees upon walking?
Does your current pain cause you to be depressed or experience suicidal thoughts?
Does your current pain interfere with your ability to sleep good at night?
Have you attempted to use any kind of hot or cold therapies to help with the pain?
Are you currently using opioids (pain medication) to assist with the pain?
If yes, how long have you been taking the medications
If you don’t use prescribed pain medication, what kind of medication do you use
Do you experience any pain relief from the oral medications that you take?
Submit
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