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Knee Clinic Intake Form

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  • YYYY slash MM slash DD
  • Personal Information

  • YYYY slash MM slash DD
  • Family Doctor (GP)

  • Emergency Contact

  • Other Information

    Please be advised that we do not accept WCB cases.
    If yes, additional intake forms are required.
  • Our 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 Information

  • 0 is no pain, 10 is severe pain
  • Physical History

  • Please mark a 1 beside any conditions you have had in the past
    Please mark a 2 beside any condition that you have presently
  • Musculoskeletal system

  • Nervous system

  • Cardio-Vascular-Resp.

  • Genito-Urinary system

  • Gastrointestinal system

  • Ear, Eyes, Nose, Throat

  • Female

  • 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 SURVEY

  • INSTRUCTIONS: 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.

  • Symptoms

    These questions should be answered thinking of your knee symptoms during this last week.
  • Stiffness

    The 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.
  • Pain

  • What amount of knee pain have you experienced in the last week during the following activities?
  • Function, daily living

    The 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.
  • For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee.
  • Function, sports and recreational activities

    The 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.
  • Quality of life

Contact Us

Call Us:
The Knee Clinic: 403-457-5633
Elite Sport Performance: 403-689-9889
Calgary PRP Clinic: 403-879-8919

Visit Us at:
535 – 10333 Southport Rd. S.W.
Calgary, AB T2W 3X6

Click Here to Email Us

Knee Brace Support or Returns

Clinic Hours

Monday – Thursday 7am to 7pm

Friday – 7am to 5pm

Saturday – 10am to 3pm

Closed Sundays

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