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Patient's Name:
Middle:
Last Name:
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Date:
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Age:
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Occupation:
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Injury to which knee?
Left
Right
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Date of this injury:
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Work Related?
Yes
No
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Describe how this injury happened:
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Has this knee been injured in the past?
Yes
No
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If yes, please describe (including dates, treatment and surgeries):
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Where is the pain?
Inside
Outside
Front
Back
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What makes the pain worse (stairs, squatting, etc.)?
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What makes the pain better (rest, meds, heat, etc.)?
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check symptoms that apply: |
At
time of injury |
Now |
| Pain |
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| Popping/Clicking |
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| Locking |
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| Swelling
- Immediate |
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| Swelling
- Late |
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| Decreased
Motion |
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| Weakness |
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| Redness
or increased warmth |
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What treatment have you received since this injury (medications, therapy, brace, surgery; include dates and doctors' names)?:
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How much better is your knee since the injury?:
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