Knee Pain Confidential Patient Health Record

How did you hear about us? *

Family
Friend
Co-Worker
Close to home/work
Dr.
Yellow pages
Drove by
Hospital
Insurance Plan

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Personal Information

Title *

Mr.
Ms.
Mrs.

Name *

First

Middle

Last

Suffix

Birth Date *

Age *

Sex *

Male
Female

Marital Status *

Single
Married
Widowed
Divorced
Separated

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email Address

Primary Phone Number

Children (Names and Ages)

Spouses Name

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Emergency Contact

Name *

First

Middle

Last

Relationship *

Spouse
Relative
Friend
Other

Primary Phone Number

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Employment Information

Are you retired? *

Occupation/Job Title

Business Name

Phone

Employer’s Email Address

Occupation (Current or Previous)

Current or previous work

Clerical?

Light Labor

Moderate Labor

Heavy Labor

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Current Health Condition

Unwanted Condition (Why you are here today?)

When did this Condition BEGIN?

Has it ever occurred before?

When ?

Is the Condition

Auto Related
Job Related
Home Injury
Slip or Fall
Lifting
Slept Wrong
Unknown Cause
Other

Explain

Date and Time of Accident

Date

Time

Condition/Pain STARTED on what Date

Do you SUFFER with ANY OTHER Condition than which you are now consulting us?

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TELL US ABOUT YOUR PAST HEALTH

Have you seen other doctors for THIS CONDITION?

Who? (Doctor's Name)

Type of Treatment

Was the treatment beneficial in resolving condition?

Explain

List the prescription drugs you are currently taking (or you may attach a list):

Name

Name (copy)

Name (copy) (copy)

Name (copy) (copy) (copy)

Dose (mg or IU)

Dose (mg or IU) (copy)

Dose (mg or IU) (copy) (copy)

Dose (mg or IU) (copy) (copy) (copy)

Times Daily

Times Daily (copy)

Times Daily (copy) (copy)

Times Daily (copy) (copy) (copy)

Upload a file

Drag & Drop Files, Choose Files to Upload

Check both current and past conditions:

Lower Back Pain
Diabetes
High Cholesterol
Leg or Foot Pain/Numbness
Hand Problems
Shingles
Prior Spinal Surgeries
Neuropathy
Knee Surgery
Spinal Fractures
Heart Attack
Kidney issues or Dialysis
Spinal Stenosis
Heart Problems
Gout
Spinal Arthritis
High/Low Blood Pressure
Hip Surgery
Sciatica
Vascular Leg Problem
Leg Fractures
Neck Pain
Vascular Surgery
Joint Replacement
Herniated Disc
Stroke
Foot Surgery

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PAST HEALTH HISTORY

Fill out carefully as these problems can affect your overall course of care.

Childhood Illness (es): LIST all health conditions. CHECK all CURRENT conditions.

ADD
chicken pox
headaches
scoliosis
atopic dermatitis (eczema)
crohn’s/colitis
hepatitis
seizure disorder
allergies/hayfever
depression
HIV
sickle cell anemia
anemia
diabetes
measles
spina bifida
asthma
ear infections
mumps
bedwetting
fetal drug exposure
psoriasis
cerebral palsy
food allergies (list below)
rash
other

Adult Illness(es): LIST all health conditions. CHECK all CURRENT conditions.

ADD
cystic kidney disease
hypertension
psychiatric problems
alzheimers
depression
influenzal pneumonia
scoliosis
anemia
diabetes (insulin dep)
liver disease
seizures
arthritis
diabetes (non insulin)
lung disease
shingles
asthma
eczema
lupus erythema (discoid)
past history of similar symptoms
cancer
emphysema
lupus erythema (systemic)
STD’s (unspecified)
cerebral palsy
eye problems
multiple sclerosis
suicide attempt(s)
chicken pox
fibromyalgia
parkinson’s disease
thyroid problems
crohn’s/colitis
heart disease
unspecified pleural effusion
vertigo
CRPS (RSD)
hepatitis
pneumonia
CVA (stroke)
HIV
psoriasis
other:

Are any of these conditions current? If so, please list

Surgery (ies): LIST All Surgical Procedures. Write the DATE of the Procedure immediately afterward.

angioplasty
cosmetic
hysterectomy
pacemaker insertion
appendectomy
D & C
joint reconstruction
rotator cuff
caesarian section
dental surgery
joint replacement
spinal fusion
cardiac catheterization
gall bladder
knee repair
tonsilectomy
carpal tunnel repair
hemorrhoidectomy
laminectomy
coronary artery bypass
hernia repair
mastectomy
other:

Please list the surgery and date of procedure

Injury (ies): Mark or List All Injuries. Write the DATE of the Injury immediately afterward.

back injury
head injury (loss of consciousness)
motor vehicle accident
broken bones
head injury (no loss of consciousness)
soft tissue injury (mild)
disability (ies)
industrial accident
soft tissue injury (moderate)
fall (severe)
joint injury
soft tissue injury (severe)
fracture
laceration (severe)
other:

Date of Injury if Applicable

PLEASE LIST BELOW ANY OTHER SERIOUS MEDICAL CONDITIONS YOU HAVE HAD:

List ALL allergies/sensitivities to medication, food, and other items here:

Item you react to

Item you react to (copy)

Item you react to (copy) (copy)

Item you react to (copy) (copy) (copy)

Reaction

Reaction (copy)

Reaction (copy) (copy)

Reaction (copy) (copy) (copy)

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Knee Pain Consult

Please list below any back, knee, or leg surgeries you've had: *

Have you had an EMG performed on your legs/feet? *

When

Do you exercise regularly? *

Describe what exercise you do

Are your symptoms worse at night? *

Around what time

What kind of problems are you having? *

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Knee Pain Consult - Symptoms

On a scale, how would you rate your symptoms?

Selected Value: 1

Describe your pain on a scale of 1 to 10, where 1 is no pain, and 10 is the worst pain possible.

When did this begin? *

What makes it better? *

What makes it worse? *

How would you describe your symptoms? *

Stabbing/Sharp
Burning
Electric Shocks
Stings
Cold
Ache
Tingling
Numbness
Pins and Needles
Swelling
Dead Feeling
Tiredness
Throbbing
Cramping

What do you think is causing your problem?

Is this condition interfering with any of the following: *

Work
Sleep
Daily Routine
Chores
Walking
Standing
Shopping

How would you describe your average knee pain over the past week?

Selected Value: 1

Describe your pain on a scale of 1 to 10, where 1 is no pain, and 10 is the worst pain possible.

Please indicate what you consider to be an acceptable level of pain after completion of the treatment, if you have to accept some pain?

Selected Value: 1

Describe your pain on a scale of 1 to 10, where 1 is no pain, and 10 is the worst pain possible.

Which of the following is true for your condition: *

It’s getting better on its own
It’s staying the same
It’s getting worst 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 three main “health goals” that you would like to accomplish: *

List the three main “health goals” that you would like to accomplish: (copy) *

List the three main “health goals” that you would like to accomplish: (copy) (copy) *

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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… *

	Not at all	A little	Moderately	Quite a bit	Extremely
Limited your ability to walk?	Not at allLimited your ability to walk? Not at all	A littleLimited your ability to walk? A little	ModeratelyLimited your ability to walk? Moderately	Quite a bitLimited your ability to walk? Quite a bit	ExtremelyLimited your ability to walk? Extremely
Limited your ability to run?	Not at allLimited your ability to run? Not at all	A littleLimited your ability to run? A little	ModeratelyLimited your ability to run? Moderately	Quite a bitLimited your ability to run? Quite a bit	ExtremelyLimited your ability to run? Extremely
Limited your ability to climb up or down stairs?	Not at allLimited your ability to climb up or down stairs? Not at all	A littleLimited your ability to climb up or down stairs? A little	ModeratelyLimited your ability to climb up or down stairs? Moderately	Quite a bitLimited your ability to climb up or down stairs? Quite a bit	ExtremelyLimited your ability to climb up or down stairs? Extremely
Made standing when doing things more difficult?	Not at allMade standing when doing things more difficult? Not at all	A littleMade standing when doing things more difficult? A little	ModeratelyMade standing when doing things more difficult? Moderately	Quite a bitMade standing when doing things more difficult? Quite a bit	ExtremelyMade standing when doing things more difficult? Extremely
Limited your balance when standing or walking?	Not at allLimited your balance when standing or walking? Not at all	A littleLimited your balance when standing or walking? A little	ModeratelyLimited your balance when standing or walking? Moderately	Quite a bitLimited your balance when standing or walking? Quite a bit	ExtremelyLimited your balance when standing or walking? Extremely
Limited how far you are able to walk?	Not at allLimited how far you are able to walk? Not at all	A littleLimited how far you are able to walk? A little	ModeratelyLimited how far you are able to walk? Moderately	Quite a bitLimited how far you are able to walk? Quite a bit	ExtremelyLimited how far you are able to walk? Extremely
Increased the effort needed for you to walk?	Not at allIncreased the effort needed for you to walk? Not at all	A littleIncreased the effort needed for you to walk? A little	ModeratelyIncreased the effort needed for you to walk? Moderately	Quite a bitIncreased the effort needed for you to walk? Quite a bit	ExtremelyIncreased the effort needed for you to walk? Extremely
Made it necessary for you to use support when walking indoors (e.g. holding on to furniture, using a cane, etc.)?	Not at allMade it necessary for you to use support when walking indoors (e.g. holding on to furniture, using a cane, etc.)? Not at all	A littleMade it necessary for you to use support when walking indoors (e.g. holding on to furniture, using a cane, etc.)? A little	ModeratelyMade it necessary for you to use support when walking indoors (e.g. holding on to furniture, using a cane, etc.)? Moderately	Quite a bitMade it necessary for you to use support when walking indoors (e.g. holding on to furniture, using a cane, etc.)? Quite a bit	ExtremelyMade it necessary for you to use support when walking indoors (e.g. holding on to furniture, using a cane, etc.)? Extremely
Made it necessary for you to use support when walking outdoors (e.g. using a cane or walker, etc.)?	Not at allMade it necessary for you to use support when walking outdoors (e.g. using a cane or walker, etc.)? Not at all	A littleMade it necessary for you to use support when walking outdoors (e.g. using a cane or walker, etc.)? A little	ModeratelyMade it necessary for you to use support when walking outdoors (e.g. using a cane or walker, etc.)? Moderately	Quite a bitMade it necessary for you to use support when walking outdoors (e.g. using a cane or walker, etc.)? Quite a bit	ExtremelyMade it necessary for you to use support when walking outdoors (e.g. using a cane or walker, etc.)? Extremely
Slowed down your walking?	Not at allSlowed down your walking? Not at all	A littleSlowed down your walking? A little	ModeratelySlowed down your walking? Moderately	Quite a bitSlowed down your walking? Quite a bit	ExtremelySlowed down your walking? Extremely
Affected how smoothly you walk?	Not at allAffected how smoothly you walk? Not at all	A littleAffected how smoothly you walk? A little	ModeratelyAffected how smoothly you walk? Moderately	Quite a bitAffected how smoothly you walk? Quite a bit	ExtremelyAffected how smoothly you walk? Extremely
Made you concentrate on your walking?	Not at allMade you concentrate on your walking? Not at all	A littleMade you concentrate on your walking? A little	ModeratelyMade you concentrate on your walking? Moderately	Quite a bitMade you concentrate on your walking? Quite a bit	ExtremelyMade you concentrate on your walking? Extremely

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Knee Pain Consult ROF

This is a confidential record of your medical history and pertinent personal information. The doctor reserves the right to discuss this information with medical and allied health professionals per the informed consent. Copies of this record can only be released by your written authorization, unless you sign here indicating that we can release copies by your verbal request.

Checkboxes (copy)

I hereby authorize release of any medical information necessary to evaluate my case or process any future claims.

Please give name, address, and office phone number of your primary care physician.

Name *

Phone

Address

Address Line 1

City

State

When were you last seen there?

May we send them updates on your treatment/condition?

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REVIEW OF SYSTEMS

Below is a list of symptoms that may seem unrelated to the purpose of your appointment. However, these questions must be answered carefully as the problems can affect your overall course of care. Please check all that apply

Constitutional *

N/A
chills
fatigue
night sweats
weight loss
daytime drowsiness
fever
weight gain

Eyes/Vision *

N/A
blindness
change in vision
field cuts
photophobia
blurred vision
double vision
glaucoma
tearing
cataracts
eye pain
itching
wear glasses/contacts

Ears, Nose and Throat *

N/A
bleeding
ear drainage
hearing loss
nosebleeds
sore throat
dentures
ear pain
history of head injury
postnasal drip
tinnitus (ringing in ears)
difficulty swallowing
fainting
hoarseness
rhinorrhea (runny nose)
TMJ problems
discharge
frequent sore throats
loss of sense of smell
sinus infections
dizziness
headaches
nasal congestion
snoring

Respiration

N/A
asthma
coughing up blood
sputum production
cough
shortness of breath
wheezing

Cardiovascular *

N/A
angina (chest pain or discomfort)
high blood pressure
shortness of breath with exertion or exercise
chest pain
low blood pressure
swelling of legs
claudication (leg pain/ache)
orthopnea (difficulty breathing lying down)
ulcers
heart murmur
palpitations
varicose vains
heart problems
paroxysmal nocturnal dyspnea (waking at night with shortness of breath)

Gastrointestinal *

N/A
abdominal pain
diarrhea
indigestion
abnormal stool caliber
vomiting blood
belching
difficulty swallowing
jaundice
abnormal stool color
black - tarry stools
heartburn
nausea
abnormal stool consistency
constipation
hemorrhoids
rectal bleeding
vomiting

Female *

N/A
birth control
cramps
irregular menstruation
vaginal bleeding
breast lumps/pain
frequent urination
pregnancy
vaginal discharge
burning urination
hormone therapy
urine retention

Male *

N/A
burning urination
frequent urination
prostate problems
erectile dysfunction
hesitancy / dribbling
urine retention

Endocrine *

N/A
cold intolerance
excessive hunger
goiter
unusual hair growth
diabetes
excessive thirst
hair loss
voice changes
excessive appetite
abnormal frequency of urination
heat intolerance

Skin *

N/A
changes in nail texture
hair loss
itching
skin lessions / ulcers
changes in skin color
hives
paresthesias
varicosities
hair growth
history of skin disorders
rash

Nervous System *

N/A
dizziness
limb weakness
numbness
slurred speech
tremor
facial weakness
loss of consciousness
seizures
stress
unsteadiness of gait
loss of balance
headache
loss of memory
sleep disturbance
strokes

Psychologic *

N/A
anhedonia
behavioral change
convulsions
memory loss
anxiety
bi-polar disorder
depression
mood change
loss or change in appetite
confusion
insomnia

Allergy *

N/A
anaphalaxis
itching
chronic nasal congestion
sneezing
food intolerance
acute nasal congestion
rash

Hematologic *

N/A
anemia
blood clotting
bruising easily
lymph node's swelling
bleeding
blood transfusion
fatigue

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Family History: Mark all that apply below. List any specific conditions past or present after has/had:

father

alive
deceased
normally developed
no significant disease
has/had a noteable illness/condition

Please list the condition your father had or has if applicable

mother

alive
deceased
normally developed
no significant disease
has/had a noteable illness/condition

Please list the condition your mother had or has if applicable

paternal grandfather

alive
deceased
normally developed
no significant disease
has/had a noteable condition

paternal grandmother

alive
deceased
normally developed
no significant disease
has/had a noteable condition

maternal grandfather

alive
deceased
normally developed
no significant disease
has/had a noteable condition

maternal grandmother

alive
deceased
normally developed
no significant disease
has/had a noteable condition

child (ren)

alive
deceased
normally developed
no significant disease
has/had a noteable condition

Please list the condition your child has or had if applicable

sibling

alive
deceased
normally developed
no significant disease
has/had a noteable condition

Please list the condition your brother or sister has/had if applicable

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Social History

Alcohol (do you drink?)

Never
Social Consumption only
Beer
Liquor
Wine

Diet (please mark all that apply)

High Fat
High Fiber
High Protein
High Salt
Low Calorie
Low Carb
Low Fiber
Low Salt
Low Sugar

Education (please mark the highest level completed):

Middle
Junior High
Votech
In High School
Did Not Finish High School
High School Diploma
Post High School Classes
Assoc/Technical Degree
In College
College Degree
In Graduate School
Graduate Degree
Doctorate
Other

Drugs

I do not use illegal drugs
I use drugs recreationally

Tobacco

Do NOT smoke cigars, cigarettes or pipe
Live with a smoker
Quit smoking
Smoke

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Insurance Information

Who Is Responsible For Your Bill? YOU and… (mark appropriate box(es))

Myself ONLY
Spouse
Worker’s Comp
Auto Insurance
Medicare
Medicaid
Other

Other (be specific)

Personal Health Insurance Carrier

Health ID Card #

Policy Holder’s Name

Group #

Policy Holder’s Date of Birth

Primary Care Physician

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Workers Compensation Injury / Auto / Personal Injury

Have you filed an injury report with your employer?

Date

Time

Carrier

Policy #

Carriers Phone #

Adjuster

Claim #:

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Knee Pain Program Qualification Questionnaire

Do you experience knee pain? *

Right
Left
Both

Do you experience knee pain at rest? *

Do you have knee osteoarthritis confirmed by imaging (x-ray/MRI)? *

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? *

Do you have morning knee stiffness lasting 30 minutes or less? *

Do you experience a grinding sensation with knee movement? *

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? *

Have you attempted physical therapy to the affected knee or participated in a personal exercise program without long-term relief? *

Have you attempted to lose weight to help with your knee pain? *

Have you used a knee brace without long-term relief? *

Has your doctor ever drained excess fluid from the affected knee(s)? *

Have you tried steroid/cortisone injection(s) to the knee without long-term relief? *

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I consent to receiving SMS text messages for appointment confirmation purposes. *

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.

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Knee Pain Confidential Patient Health Record

Personal Information

Emergency Contact

Employment Information

Occupation (Current or Previous)

Current Health Condition

TELL US ABOUT YOUR PAST HEALTH

List the prescription drugs you are currently taking (or you may attach a list):

PAST HEALTH HISTORY

List ALL allergies/sensitivities to medication, food, and other items here:

Knee Pain Consult

Knee Pain Consult - Symptoms

Walking Scale Questionnaire

Knee Pain Consult ROF

Please give name, address, and office phone number of your primary care physician.

REVIEW OF SYSTEMS

Family History: Mark all that apply below. List any specific conditions past or present after has/had:

Social History

Insurance Information

Workers Compensation Injury / Auto / Personal Injury

Knee Pain Program Qualification Questionnaire

Stop struggling, start living

About Us

Hours

Contact

Get Pain Relief Now –
Pay only $49 for your first consultation
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Get Pain Relief Now –
Pay only $49 for your first consultation
Limited Time Offer

Knee Pain Confidential Patient Health Record

Personal Information

Emergency Contact

Employment Information

Occupation (Current or Previous)

Current Health Condition

TELL US ABOUT YOUR PAST HEALTH

List the prescription drugs you are currently taking (or you may attach a list):

PAST HEALTH HISTORY

List ALL allergies/sensitivities to medication, food, and other items here:

Knee Pain Consult

Knee Pain Consult - Symptoms

Walking Scale Questionnaire

Knee Pain Consult ROF

Please give name, address, and office phone number of your primary care physician.

REVIEW OF SYSTEMS

Family History: Mark all that apply below. List any specific conditions past or present after has/had:

Social History

Insurance Information

Workers Compensation Injury / Auto / Personal Injury

Knee Pain Program Qualification Questionnaire

Stop struggling, start living

Get Pain Relief Now – Pay only $49 for your first consultation Limited Time Offer

Get Pain Relief Now – Pay only $49 for your first consultation Limited Time Offer

Get Pain Relief Now –
Pay only $49 for your first consultation
Limited Time Offer

Get Pain Relief Now –
Pay only $49 for your first consultation
Limited Time Offer