• Anterior Cruciate Ligament (ACL) Reconstruction and Revision ACL Reconstruction
  • Rotator Cuff Repair and Revision Rotator Cuff Repair
  • Shoulder Stabilization (Repair for Shoulder Dislocation/Instability)
  • Ulnar Collateral Ligament Reconstruction (Tommy John Surgery)
  • Sports Medicine Surgery of Knee, Shoulder, Elbow
  • Board Certified Orthopedic Surgeon
  • Subspecialty Certified in Orthopedic Sports Medicine
  • Fellow, American Academy of Orthopaedic Surgeons
  • Member of American Orthopaedic Society for Sports Medicine
  • Member of Arthroscopy Association of North America
  • Stem Cell Therapy
  • Platelet Rich Plasma (PRP)
  • Cartilage Restoration Surgery
  • Osteotomies about the Knee
  • Tendon Repair
  • Rotation Medical Collagen Patch for Rotator Cuff

Knee Injury Questionnaire for New Patients

Please complete this form BEFORE your appointment.

Name*


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Age*
Height*
Weight*
Email Address*
Best Daytime Phone*
Who is your primary care physician?
When did you last see him/her?
Have you ever had any of the following (in the past)?
 Asthma Balance Problems Bladder or Urinary Infections Blood in Stools Blood Clots Cancer Chest Pain Chronic Bronchitis Cramping in Leg While Walking Colitis Deep Venous Thrombosis Diabetes Dizziness Emphysema Fainting Frequent Bloody Noses or Bleeding Gums Gallstones Heart Attack Heart Murmur Heart Surgery High Blood Pressure High Cholesterol Joint Replacement Kidney Stones Osteoporosis Poor Circulation Recurrent Infections Shortness of Breath Slowly Healing Wounds Stomach Ulcer NORMAL. I've had none of the above.
Type of Cancer?
Review of Systems...

Do you currently have any of the following?
 Reaction of NSAID/anti-inflammatory medications (Advil, ibuprofen, Naproxen, Indocin, Celebrex, etc.) Fever or chills. Recent weight gain or recent weight loss. Changes in vision, sensitivity to light, blurred vision, double vision. Change in hearing, bloody noses, sore throat, cough. Shortness of breath, chest pain, wheezing, coughing of blood. Palpitations, light headedness, dizziness. Loss of appetite, weight loss, pain with swallowing, nausea, vomiting, abdominal pain or bloating, blood in your stools, diarrhea, constipation. Difficulty urinating, pain with urination, blood in your urine. Rashes, insect bites, new skin lesions. NORMAL. I've had none of the above.
What medications do you take?
Are you allergic to any medications?
 Yes No
To which medications are you allergic?
Do you smoke?
 Yes No
How many packs per day?
How much alcohol do you drink?
What surgeries have you had in the past?
Knee History...

To which knee do the following apply?
 Right Left
When did your knee problem begin?
How did it start?
 Sports Injury Work Injury Overuse (Running, cycling, swimming, etc.) Work Overuse Gradually Spontaneously (For no apparent reason.)
Have you had this problem before?
 Yes No
What part of your knee hurts?
 Front Behind Kneecap Inner (Medial) Side Outer (Lateral) Side Behind the Knee
What makes the pain worse?
 Activity Prolonged standing. Prolonged sitting with knee bent (i.e. in a theatre). Running, but not walking/standing. Going up or down stairs. Squatting Kneeling Twisting or pivoting with this leg.
Does the pain wake you up from sleep?
 Yes No
Is the pain worse when you first start walking and then better when you are “warmed up”?
 Yes No
Do you have any of the following?
 Painful popping. Sensation of catching. (Something getting caught/pinched between the bones.) Locking (Suddenly unable to straighten the knee because something obstructs it.) Grinding Swelling None of the above.
Does the knee ever...
 Give way? (The bones slip out of place.) Buckle? Slip out of joint? Get stuck?
Describe your job's physical demands...
 Manual labor including kneeling, squatting, climbing, carrying, etc. (Construction, laborer.) Moderate: Walking, stairs, on feet all or most of day. Office environment with frequent walking and time on your feet. Desk Job Student Athlete Other
Are you currently working at your usual job?
 Yes No, light duty. No, off work due to injury. No, off work for other reasons.
What were your typical most strenuous recreational activities before your knee problem began?
 High intensity sports (football, basketball, racquetball, etc.) Moderate intensity sports (recreational skiing, running, cycling, etc.) Low intensity sports (walking, golf, etc.) Activities of daily living.
What are your most strenuous activities since your knee problem began?
 High Intensity Moderate intensity sports (recreational skiing, running, cycling, etc.) Low intensity sports (walking, golf, etc.) Manual Labor Desk Job Activities of daily living.
To what type of activities do you intend to return after your knee problem resolves?
 High Intensity Moderate intensity sports (recreational skiing, running, cycling, etc.) Low intensity sports (walking, golf, etc.) Manual Labor Desk Job Activities of daily living.
Do you run for exercise/recreation? If so, how many miles per week?
 Less than 10 miles per week. 10-20 miles per week. More than 20 miles per week. Don't run.
What prior injuries have you had to this knee?
 NONE Cartilage or Meniscus Tear Ligament Tear (ACL, MCL, PCL, LCL) Bone Chips Sprain/Strain Patellar Dislocation Other
Have you had an MRI?
 Yes No
What did the MRI show?
What surgeries have you had on this knee?
 Arthroscopy Cartilage / Meniscectomy (removal of cartilage) Cartilage / Meniscus Repair Debridement / cleaning out ACL reconstruction Other
Year of your Arthroscopy?
Year of your Cartilage/Meniscectomy?
Year of your Cartilage/Meniscus Repair?
Year of your Debridement?
Year of your ACL Reconstruction?
What other surgery did you have, and in what year?
What other surgery did you have, and in what year?
What are your goals for this visit?
 Gain information regarding your problem. Make sure it is okay to remain active. Correct the problem as long as it does not need surgery. Correct the problem even if it needs surgery.
eSignature

 I certify that I am the patient named above, and that all the responses contained in this form are accurate to the best of my knowledge. I certify that I am the parent or legal guardian of the patient named above, and that all the responses contained in this form are accurate to the best of my knowledge.
Name of Parent or Legal Guardian*


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  • Harvard University
  • Columbia University
  • Baylor College of Medicine
  • NYU Hospital for Joint Diseases
  •  American Orthopaedic Society for Sports Medicine (AOSSM)
  • American Academy of Orthopaedic Surgeons
  • Arthroscopy Association of North America – AANA
  • J. Robert Gladden Orthopaedic Society (JRGOS)
  • Texas Southern University