Step 1 of 4 25% Date* YYYY slash MM slash DD Personal InformationName* First Last Personal Health Number* Home Address* Street Address Address Line 2 City Postal Code Email Address* Home PhoneCell PhoneBusiness PhoneBirth Date* YYYY slash MM slash DD Height* Weight* Marital Status* M S W D Current Occupation* Family Doctor (GP)Name First Last Location Phone NumberEmergency ContactName First Last Phone NumberRelationship Other InformationWhom can we thank for your referral? We would like to send them a token of our appreciation. Is this a workplace injury?* Yes No Please be advised that we do not accept WCB cases. Is your injury the result of a motor vehicle accident?* Yes No If yes, additional intake forms are required. The healthcare team in this clinic meets regularly to discuss interdisciplinary co-treatment of our patients. If you do not wish us to discuss your case, please check here I do not wish you to discuss my case Consent I consent to my information being used in future researchOur clinic is committed to evidence-based practice and contributing to the scientific research community. All patient information used in research is kept strictly confidential and is used only with permission of the patient. Do you consent to allow your information to be used in future research? Missed office Visits: A charge of $80 will be made in the event of a missed office visit, or if less than 24 hours’ notice is given when canceling an appointment. Re-examinations: Re-examinations are done in the event of a six month time lapse between office visits Health InformationHave you had any previous treatment to your knee? Yes No For what reason? What approach was taken? In your own words, please describe your chief complaint and when you first noticed the problem.What seems to make the problem better?What seems to make the problem worse?What type of pain is it? Sharp Stabbing Achy Burning Dull Diffuse Localized Does the pain radiate? Yes No At what time of the day does your pain seem to be at its worst? Does your knee Lock Make cracking noises Give out on you Rate the pain you are experiencing now0123456789100 is no pain, 10 is severe pain Physical HistoryPlease mark a 1 beside any conditions you have had in the past Please mark a 2 beside any condition that you have presently Musculoskeletal systemNeck Problems 1 2 Upper back problems 1 2 Shoulder problems 1 2 Elbow/wrist problems 1 2 Low back problems 1 2 Knee problems 1 2 Ankle/foot problems 1 2 Arthritis 1 2 Nervous systemNumbness 1 2 Loss of feeling 1 2 Headaches 1 2 Dizziness 1 2 Fainting 1 2 Confusion 1 2 Depression 1 2 Forgetfulness 1 2 Cardio-Vascular-Resp.Chest pain 1 2 High blood pressure 1 2 Difficult breathing 1 2 Persistent cough 1 2 Coughing phlegm/blood 1 2 Lung problems 1 2 Varicose veins 1 2 Diabetes 1 2 Hypoglycemia 1 2 Genito-Urinary systemPainful urination 1 2 Excessive urine 1 2 Scanty urine 1 2 Discolored urine 1 2 Gastrointestinal systemPoor appetite 1 2 Excessive hunger 1 2 Abdominal pain 1 2 Excessive thirst 1 2 Nausea/vomiting 1 2 Diarrhea 1 2 Constipation 1 2 Bloody/black stool 1 2 Liver/gallbladder trouble 1 2 Weight trouble 1 2 Ear, Eyes, Nose, ThroatEye problems 1 2 Vision problems 1 2 Ear discharge 1 2 Ear pain 1 2 Ear ringing 1 2 Hearing loss 1 2 Sore throat 1 2 Allergies 1 2 Hoarseness 1 2 FemalePremenstrual syndrome 1 2 Abnormal vaginal discharge 1 2 Abnormal vaginal bleeding 1 2 Pregnancy 1 2 Breast pain, and/or lumps 1 2 Your first visit to the office includes both an initial consultation as well as an office visit. At the discretion of the doctor, your first visit may not consist of actual treatment. Attire/Hygiene Some treatments necessitate direct skin contact. Please bring shorts to each appointment and bathe before attending your appointment. Please refrain from wearing any cologne, perfumes or scented lotions while in the clinic. KOOS KNEE SURVEYINSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to perform your usual activities. Answer every question by ticking the appropriate box, only one box for each question. If you are unsure about how to answer a question, please give the best answer you can. SymptomsThese questions should be answered thinking of your knee symptoms during this last week.S1. Do you have swelling in your knee? Never Rarely Sometimes Often Always S2. Do you feel grinding, hear clicking or any other type of noise when your knee moves? Never Rarely Sometimes Often Always S3. Does your knee catch or hang up when moving? Never Rarely Sometimes Often Always S4. Can you straighten your knee fully? Never Rarely Sometimes Often Always S5. Can you bend your knee fully? Never Rarely Sometimes Often Always StiffnessThe following questions concern the amount of joint stiffness you have experienced in your knee during the last week. Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint. S6. How severe is your knee joint stiffness first thing in the morning? None Mild Moderate Severe Extreme S7. How severe is your knee stiffness after sitting, lying or resting later in the day? None Mild Moderate Severe Extreme PainP1. How often do you experience knee pain? Never Monthly Weekly Daily Always What amount of knee pain have you experienced in the last week during the following activities? P2. Twisting/pivoting on your knee None Mild Moderate Severe Extreme P3. Straightening knee fully None Mild Moderate Severe Extreme P4. Bending knee fully None Mild Moderate Severe Extreme P5. Walking on flat surface None Mild Moderate Severe Extreme P6. Going up or down stairs None Mild Moderate Severe Extreme P7. At night while in bed None Mild Moderate Severe Extreme P8. Sitting or lying down None Mild Moderate Severe Extreme P9. Sitting upright None Mild Moderate Severe Extreme Function, daily livingThe following questions concern your physical function. By this we mean your ability to move around and look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee.A1. Descending stairs None Mild Moderate Severe Extreme A2. Ascending stairs None Mild Moderate Severe Extreme A3. Rising from sitting None Mild Moderate Severe Extreme A4. Standing None Mild Moderate Severe Extreme A5. Bending to floor/picking up objects None Mild Moderate Severe Extreme A6. Walking on a flat surface None Mild Moderate Severe Extreme A7. Getting in/out of car None Mild Moderate Severe Extreme A8. Going shopping None Mild Moderate Severe Extreme A9. Putting on socks/stockings None Mild Moderate Severe Extreme A10. Taking off socks/stockings None Mild Moderate Severe Extreme A11. Rising from bed None Mild Moderate Severe Extreme A12. Lying in bed (turning over, maintaining knee position None Mild Moderate Severe Extreme A13. Getting in/out of bath None Mild Moderate Severe Extreme A14. Sitting None Mild Moderate Severe Extreme A15. Getting on/off toilet None Mild Moderate Severe Extreme For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc.) None Mild Moderate Severe Extreme A17. Light domestic duties (cooking, dusting, etc.) None Mild Moderate Severe Extreme Function, sports and recreational activitiesThe following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced in the last week due to your knee. SP1. Squatting None Mild Moderate Severe Extreme SP2. Running None Mild Moderate Severe Extreme SP3. Jumping None Mild Moderate Severe Extreme SP4. Twisting/pivoting on your injured knee None Mild Moderate Severe Extreme SP5. Kneeling None Mild Moderate Severe Extreme Quality of lifeQ1. How often are you aware of your knee problem? Never Monthly Weekly Daily Always Q2. Have you modified your lifestyle to avoid potentially damaging activities to your knee? Never Mildly Moderately Severely Totally Q3. How much are you troubled with lack of confidence in your knee? Never Mildly Moderately Severely Totally Q4. In general, how much difficulty do you have with your knee? Never Mildly Moderately Severely Totally
