Knee Evaluation Form

Name

Date

Age

Involved Knee

Is one worse than the other?

When did problem start?

Did it swell?

Yes

No

When did it swell?

Does it swell now?

Yes

No

Was there an Injury?

Yes

No

If injured, did you feel/hear a pop?

Yes

No

If not injured, what activity do you think caused/contributed to the problem?

Describe what happened to the knee (i.e. twisted skiing, hit on outside part of knee)

Do you have any of the following feelings? (CTRL+Click for multiple selection)

Pain is located on?

What makes pain worse? (CTRL+Click for multiple selection)

What makes pain better? (CTRL+Click for multiple selection)

How severe is the pain on average? (none) 0 1 2 3 4 5 6 7 8 9 10 (extreme)

Medications taken for this? (CTRL+Click for multiple selection)

If you selected "Other" above, please describe.

Injections? Please select all that apply. (CTRL+Click for multiple selection)

If "Other" is selected above, please describe.

Percent improvement with injection(s)

Previous treatment for this problem: (CTRL+Click for multiple selection)

Previous knee surgery? Provide Date and Surgeon.

Previous injuries to this knee/date(s)

Have you had any of these tests for this condition? (CTRL+Click for multiple selection)

If "Other" is selected above, please describe.

Sports/recreational activities

Level of sport currently: (CTRL+Click for multiple selection)

Occupation

Current School and Grade Level

Goals after treatment for this problem

Intro