FULL NAME
PHONE NUMBER
AGENT
Please Select
ATHAN
STEPHEN
MARK
ALECIA
DAWN
MIKE
MELINDA
BRIDGET
LUCAS
DAVE
RAYZA
NICOLE
BRITTANY
LA'TRICE
CLIENT
Please Select
IHPS
NEW FRONTIER MEDICAL
EXCEL
AWMS
ORTHO CONNECT
WIMEDICAL
HISTORY
Any history of a knee sprain, knee buckling, or grasshopper knee (kneecap slides to one side abruptly)?
KNEE SPRAIN
KNEE BUCKLING
GRASSHOPPER KNEE
NONE
Any history of trauma, ligament injury, meniscus surgery, knee replacement, or failed knee surgery?
TRAUMA
LIGAMENT INJURY
MENISCUS SURGERY
KNEE REPLACEMENT
FAILED KNEE SURGERY
NONE
Any history of conditions such as rheumatoid arthritis, osteoarthritis, or degenerative joint disease?
RHEUMATOID ARTHRITIS
OSTEOARTHRITIS
DEGENERATIVE JOINT DISEASE
NONE
Any history of a congenital deformity, multiple sclerosis, cerebral palsy, stroke or paraplegia?
CONGENITAL DEFORMITY
MULTIPLE SCLEROSIS
CEREBRAL PALSY
STROKE
PARAPLEGIA
NONE
Any history of obesity or being overweight by more than 20 pounds?
Please Select
YES
NO
Additional Questions
Where is your pain located - left, right, or both knee's?
Please Select
LEFT
RIGHT
BI-LATERAL
What type of pain do you have? (Aching, burning, cramping, stabbing, sharp or dull)
ACHING
BURNING
CRAMPING
SHARP
DULL
STABBING
NONE
Please rate the severity of your pain, 10 being the hightest
Please Select
1
2
3
4
5
6
7
8
9
10
Does increased movement, such as simply walking, increase your pain?
YES
NO
Submit
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