Knee Pain
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Patient Information
*
Please provide the patient's name as it appears on their driver's license, state identification card, or government issued identification card.
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Gender
Male
Female
Knee Pain
* Required Information
*
Affected Knee
Left
Right
Onset of Symptoms
*
Which best describes how your symptoms began?
Due to an injury
Gradual onset (not due to an injury)
Sudden onset (not due to an injury)
How long ago did the symptoms begin?
1
2
3
4
5
6
7
8
9
10
More than 10
Days ago
Weeks ago
Months ago
Years ago
If you do not remember when your symptoms began, please describe how long you have been experiencing the symptoms:
Over the last:
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16 or more
Weeks
Months
Years
*
Timing
Occasional
Intermittent
Daytime
Rare
Constant
Nighttime
Pain causes me to wake up from sleep
*
Where did your problem start?
Not sure
At work
Non-vehicle accident
During athletic activities
At home
Motor vehicle accident
*
What caused your problem?
Repetitive motion
Aging
Bending
Fall or direct blow
Lifting
Twisting
Not sure
Pain
How much pain are you experiencing...
0 = no pain
10 = Intolerable
*
Now:
🙂
0
1
2
3
4
5
6
7
8
9
10
🙁
*
At its worst:
🙂
0
1
2
3
4
5
6
7
8
9
10
🙁
Quality
Burning
Stinging
Aching
Sharp
Stabbing
Throbbing
Dull
Associated Signs and Symptoms
Popping
Locking
Stiffness
Catching
Giving way
Weakness
Numbness
Tingling
*
Progression
Worsening
Unchanged
Improving
What makes your pain worse?
Lying down
Running
Standing
Twisting
Getting out of a chair
Climbing stairs
Jumping
Walking
Sitting
*
What makes your pain better?
Medications
Previous surgery
Ice
Exercise
Physical therapy
Heat
Using a brace
Injections
Rest
Elevation
Chiropractor
Standing
Stretching
Sitting
Using crutches
Changing activities
Walking
Anti-inflammatories
(aspirin type medicines)
Nothing makes the pain better
Treatment History
*
Have you gone to any other locations for today's problem?
Chiropractor
Orthopedic physician
Urgent care / Emergency room
Primary care provider
Physical therapy
None
*
Have you had any of the following for today's problem?
No
X-Ray
CT Scan
MRI
Work History
*
Are you currently working?
Yes
No
Disabled
Retired
*
Are you currently on any work restrictions?
No
Yes
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Online Health Forms by PatientLink® Enterprises Inc.
Oklahoma City, OK 73189
Form Number 511
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