Application for Knee Pain TreatmentWhat to expect from your first visitPlease enable JavaScript in your browser to complete this form.NameSocial Security #DateBirth DateAgeSexMaleFemaleMarital StatusSingleMarriedWidowedDivorcedSeparatedAddressAddress Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeCell PhoneEmail *Spouse’s NameOccupation (Current or Previous)RetiredNoYesEmergency Contact NameEmergency Contact PhoneHeightWeightWhat Do You Think Is Causing Your Problem?Is This Condition Interfering With Any Of the Following?WorkSleepDailyRoutineChoresWalkingStandingShoppingHow Would You Rate Your Average Knee Pain This Past Week? (10 is the worst) Selected Value: 1What Would You Consider To Be An Acceptable Level Of Pain After Treatment? Selected Value: 1In the past 2 weeks, how much has your knee pain…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.Limited your ability to walk? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyLimited your ability to run? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyLimited your ability to climb up or down stairs? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyMade standing more difficult? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyLimited your balance when walking or standing? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyLimited how far you are able to walk? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyIncreased the effort needed to for you to walk? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyMade it necessary for you to use support when walking (e.g. holding on to furniture, using a cane, walker etc.)? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelySlowed down your walking? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyAffected how smoothly you walk? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyMade you concentrate on your walking? Selected Value: 11 -Not at All 2 - A Little 3 - Moderately 4- Quite a Bit 5 - ExtremelyPatient or Guardian Signature Clear SignatureDatePrint NameSubmit
