Knee Pain Knee Questionnaire Fill out the form below to the best of your ability. Section 1: Current SymptomsDo you currently have Knee Pain?(Required) Yes No If yes, which knee?(Required) Left Right Both Rate your pain (0 = no pain, 10 = worst pain)(Required) 1 2 3 4 5 6 7 8 9 10 Was there an injury?(Required) Yes No Please explain the InjuryIs your pain:(Required) Sharp Dull Achy Burning Stiff Does your knee feel swollen?(Required) Yes No Does your knee feel unstable or give out?(Required) Yes No Section 2: Mobility and FunctionDo you have difficulty bending your knee fully?(Required) Yes No Do you have difficulty straightening your knee fully?(Required) Yes No Pain with stairs?(Required) Going up Going down Both None Pain with squatting?(Required) Yes No Pain with walking?(Required) Yes No Pain with running?(Required) Yes No Pain after sitting for long periods?(Required) Yes No Do you feel stiffness in the morning?(Required) Yes No Section 3: Activity and LifestyleHow active are you?(Required) Low Moderate High Do you participate in sports?(Required) Yes No If yes, which?Has knee pain limited your activity?(Required) Yes No Do you avoid certain movements due to knee discomfort?(Required) Yes No OccupationSection 4: Previous CareHave you had imaging (X-ray/MRI)?(Required) Yes No Have you had physical therapy?(Required) Yes No Have you had injections?(Required) Yes No Have you had knee surgery?(Required) Yes No What treatments have helped?What treatments have not helped?Section 5: GoalsWhat are your main goals for your knee?(Required)What activities would you like to return to?(Required)How motivated are you to improve your knee health? (1-10):(Required) 1 2 3 4 5 6 7 8 9 10 Section 6: Contact InformationName(Required) First Last Phone(Required)Email(Required)
