Knee Pain Intake Form

Knee Pain Intake Form

Complete this before your appointment and your provider can be better prepared during their time with you.
Name*

First NameLast Name
Nickname
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date:*

MonthDayYear
Date
Email address:*
example@example.com
Cell Phone*
Preferred Method of Contact
Marital Status*

SingleMarriedDivorcedWidowed
Sex

FemaleMale
Spouse's Name
Current or Previous Work

ClericalLight LaborModerate LaborHeavy Labor
Your Occupation
Retired?

YesNo
In Case of Emergency Contact*
Phone Number*
How did you hear about our office?*
Tell Us About Your Past Health

Please check all that apply
What kind of problem(s) are you having?*
When did this begin?*
On a Scale of 0-10 (0=best, 10=worst), how would you rate your symptoms*
How would you describe your symptoms?*

Stabbing/sharpElectric shocksColdTinglingSwellingBurningStingsAchesNumbnessTirednessCrampingPressureOther
What makes it better?*
What makes it worse?*
Are your conditions worse at night?

YesNo
Is this condition interfering with any of the following?

SleepWorkDaily routineChoresWalkingStandingShoppingExerciseOther
Please check all that apply - choose multiple

Lower back painLeg or foot pain/numbnessNeck painSpinal StenosisSpinal ArthritisSciaticaHerniated DiscDiabetesHand problemsNeuropathyFoot problemsHeart problemsHigh/Low Blood pressureVascular Leg problemsVascular surgeryStrokeHigh CholesterolShinglesKnee SurgeryKidney IssuesGoutHip problemsJoint replacementShoulder problemsHeadaches/MigrainesPlantar FascitisTendonitisBursitisOther
Please list below any serious medical conditions you have had
List individually with dates if possible
List any BACK, KNEE, or LEG SURGERIES you've had
Current Pain Levels
How would you describe your average knee pain over the past week? (0=no pain 10=worst pain possible)*
Which of the following is true for your condition?*

It's getting better on its ownIt's staying the sameIt'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.
List the main goals that you would like to accomplish.
Please indicate what you consider to be an acceptable level of pain after completion of the treatment (if you have to accept some pain.) 0=no pain 10=worse pain possible*
Please list any medication and/or vitamins/supplements you are currently taking.*
Informed Consent and Insurance Information

Informed consent for treatment/diagnostic Testing

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of the above listed patient. I authorize this office and its staff to examine and treat my condition as the medical professionals see fit, including having diagnostic x-ray examination if necessary.
Signature*

Clear
Date*

MonthDayYear
Date
For Females: Verification of Pregnancy Status
**This is to certify that, to the best of my knowledge, I am not pregnant and give my persmission to have diagnostic x-ray if necessary** (if you are unsure of your pregnancy status, it is very important that you inform your care provider prior to any diagnostic imaging.)
Signature

Clear
Date

MonthDayYear
Date
Release of Information
This is confidential record of my medical history and pertinent personal information. The doctor/nurse practitioner reserves the right to discuss this information with medical and allied health professionals per this informed consent. Copies of this record can only be released by your written authorization. Copies of this record can only be released by your written authorization.
Signature*

Clear
Date*

MonthDayYear
Date
Insurance Information
Primary Insurance Company
Subscriber ID
Group ID
Name and Date of Birth of Primary Account Holder
Insurance Card (back)

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Insurance Card (front)

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Knee Pain Intake Form

Tell Us About Your Past Health

Please list below any serious medical conditions you have had

Current Pain Levels

For Females: Verification of Pregnancy Status

Release of Information

Insurance Information