Apply Here Apply For Our Knee Pain Program Step 1 of 5 20% Patient Information:Name(Required)SSN(Required)Date(Required) MM slash DD slash YYYY Date of Birth(Required) MM slash DD slash YYYY AgeSex(Required) Male Female Marital Status Married Single Divorced Widowed # of Children(Required)Address(Required)City(Required)State(Required)Zip(Required)PhoneEmail Spouse’s Name(Required)Spouse’s Phone NumberYour Occupation(Required)Retired? Yes No Current or Previous Work | Clerical Yes No Labor Light Labor Moderate Labor Heavy Labor In Case of Emergency Contact(Required)Emergency PhoneTELL 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 (A1C = _________________) Hand Problems Neuropathy Heart Attack Heart Problems High/Low Blood Pressure Vascular Leg Problems Vascular Surgery _________________ Stroke High Cholesterol 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:List Add RemovePLEASE LIST BELOW ANY SERIOUS MEDICAL CONDITIONS YOU HAVE HAD:NAME OF YOUR PRIMARY CARE PHYSICIANMAY WE CONTACT THEM WITH UPDATES REGARDING YOUR TREATMENT? Yes No PLEASE LIST BELOW ANY BACK, KNEE, OR LEG SURGERIES YOU’VE HAD? Add RemoveHAVE YOU HAD AN EMG PERFORMED ON YOUR LEGS/FEET? Yes No WHEN?DO YOU EXERCISE REGULARLY? Yes No WHAT?ARE YOUR SYMPTOMS WORSE AT NIGHT? Yes No AROUND WHAT TIME? WHAT KIND OF PROBLEM(S) ARE YOU HAVING?ON A SCALE, HOW WOULD YOU RATE YOUR SYMPTOMS (10 is the worst) 1 2 3 4 5 6 7 8 9 10 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 Work Daily Routine Chores Walking Standing Shopping CURRENT PAIN LEVELSHow would you describe your average knee pain over the past week? 1 2 3 4 5 6 7 8 9 10 NO PAIN TO WORST PAIN POSSIBLEPlease indicate what you consider to be an acceptable level of pain after completion of the treatment, if you have to accept some pain? 1 2 3 4 5 6 7 8 9 10 NO PAIN TO WORST PAIN POSSIBLEPlease indicate on these drawings the body area(s) where you are currently experiencing symptoms: WHICH OF THE FOLLOWING IS TRUE FOR YOUR CONDITION: It’s getting better on its own It’s staying the same It'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: Add RemoveList the three main “health goals” that you would like to accomplish: Add RemoveSTATEMENTA. I hereby authorize release of any medical information necessary to evaluate my case or process any future claims. B. I authorize payment of any medical benefits from third parties for any future charges submitted to be paid directly to this office We invite you to discuss with us any questions regarding our services and or fees. The best health services are based on a friendly, mutual understanding between the provider and patient. I understand the above information and guarantee this form was completed correctly to the best of my knowledge. I understand it is my responsibility to inform this office of any changes in my medical or insurance status. SignatureDate MM slash DD slash YYYY HOW DID YOU HEAR ABOUT OUR OFFICE? WALKING SCALE QUESTIONNAIRE These questions ask about limitations to your walking due to knee pain during the past 2 weeks. For each statement please circle the one number that best describes your degree of limitation. Please check you have circled one number for each question. Please hand this to the doctor at the start of your consultation.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 - EXTREMELYLIMITED YOUR ABILITY TO WALK? 1 2 3 4 5 LIMITED YOUR ABILITY TO RUN? 1 2 3 4 5 LIMITED YOUR ABILITY TO CLIMB UP OR DOWN STAIRS? 1 2 3 4 5 MADE STANDING WHEN DOING THINGS MORE DIFFICULT? 1 2 3 4 5 LIMITED YOUR BALANCE WHEN STANDING OR WALKING? 1 2 3 4 5 LIMITED HOW FAR YOU ARE ABLE TO WALK? 1 2 3 4 5 INCREASED THE EFFORT NEEDED FOR YOU TO WALK? 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.)? 1 2 3 4 5 MADE IT NECESSARY FOR YOU TO USE SUPPORT WHEN WALKING OUTDOORS (E.G. USING A CANE OR WALKER, ETC.)? 1 2 3 4 5 SLOWED DOWN YOUR WALKING? 1 2 3 4 5 AFFECTED HOW SMOOTHLY YOU WALK? 1 2 3 4 5 MADE YOU CONCENTRATE ON YOUR WALKING? 1 2 3 4 5 THANK YOU FOR COMPLETING THIS QUESTIONNAIRE WALKING SCALE DISABILITY SCORE: < 13 NORMAL, 13-27 MILD, 28-45 MODERATE, >63 SEVERE DISABILITY BLUEPRINT TO HEALTHCARE/WEIGHT LOSS/NEUROPATHY/KNEE PAIN KNEE PAIN PROGRAM QUALIFICATION QUESTIONNAIRE (PLEASE ANSWER ALL THE FOLLOWING QUESTIONS BY CIRCLING ONE ANSWER PER QUESTION)THANK YOU FOR COMPLETING THIS QUESTIONNAIRE. PLEASE RETURN TO THE FRONT DESK. 1. Do you experience knee pain? Right Left Both 2. Do you experience knee pain at rest? Yes No 3. Do you have knee osteoarthritis confirmed by imaging (x-ray/MRI)? Yes No Unsure 4. Has your knee pain interfered with activities (such as walking, going up/down stairs and/or standing) for at least six months? Yes No 5. Do you have morning knee sti ness lasting 30 minutes or less? Yes No 6. Do you experience a grinding sensation with knee movement? Yes No 7. 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? Yes No 8. Have you attempted physical therapy to the a ected knee or participated in a personal exercise program without long-term relief? Yes No 9. Have you attempted to lose weight to help with your knee pain? Yes No 10. Have you used a knee brace without long-term relief? Yes No 11.Has your doctor ever drained excess fluid from the a ected knee(s)? Yes No 12.Have you tried steroid/cortisone injection(s) to the knee without long-term relief? Yes No
