KNEE
Division of Sports Medicine
Howard Luks, M.D.
Chief
Patient Intake Form
Name ______Date ______
Occupation ______Age ______
1)Who sent you to see us? Name ______
Address ______Phone ______
2)Who is your Internist or Primary Care Physician?
Full Name ______Phone ______
Address ______
City, State, Zip ______
3)Chief Complaint/Current Illness:
a) Is your problem in the: Right Knee Left Knee
b) What is your chief complaint?______
______
c) How long have you had this problem? ______
d) Is your problem getting: Worse Better Staying the same
e) Was this a result of an injury? Yes No
If yes, please describe how it happened: ______
______
If yes, is this a worker’s compensation injury? Yes No (if no, advance to question #5)
4)Work-Related Injury:
a)Job title: ______
b)How long have you worked for this employer? ______
c)Date of injury: ______
d)Are you: off workmodified duty full duty
e)If you are not working full duty, what date did you last do so: ______
5)If PAIN is one of your complaints, please complete the following questions. If not, advance to Question #6.
Is your pain located in the:
Front Back Inside surface of knee Outside surface of knee Behind kneecap
b) Rate the average intensity of your pain/discomfort. (0=no pain, 10=severe pain)
0 1 2 3 4 5 6 7 8 9 10
c) Describe your Pain:Intermittent Constant
DullSharp Throbbing
TightBurning Tingling
6)Timing
1)Is your pain worse at any particular time of the day? Morning Evening Night
2)Does your knee allow you to sleep comfortably? Yes No
7)Activity-Related Symptoms:
1)Is your knee comfortable at rest?Yes No
2)Can you walk without using supports (brace, crutches, cane, etc.)? Yes No
3)Can you walk without a limp? Yes No
4)Can you walk without your knee locking or catching? Yes No
5)Can you walk up one flight of stairs? Yes No
6)Can you walk up five flights of stairs?Yes No
7)Can you run the length of one block?Yes No
8)Can you run one mile? Yes No
9)Does your knee allow you to pivot, change directions, or jump
without“giving way”?Yes No
10)Does your knee allow you to perform your normal activities of daily living
(other than work or sport)? Yes No
11)Does your knee allow you to participate in sports? Yes No
12)Can you participate in sports at the level of competition you desire? Yes No
13)Does your knee allow you to work full-time at your job?Yes No
8)Do you ever have any of these additional symptoms?
YESNO If yes, describe
Stiffness ______
Numbness ______
Swelling ______
Instability ______
Weakness ______
Painful ______
Roughness ______
Other ______
9)Have you tried any of the below? Relief of Symptoms?
YESNO
Medication Type: ______
Physical If yes, how long did you attend? ______
Therapy When was your last session? ______
Injections If yes, where were they? ______
Other Describe: ______
10)Please list all medications you currently use with dosage and frequency: ______
______
11)Do you have any allergies? Yes No If yes, please list ______
______
12)Are you currently or have you ever had problems with the following:
YESNODescribe all “YES” responses
Heart Problem ______
Breathing, Lungs ______
High Blood Pressure ______
Cancer ______
Diabetes ______
Arthritis ______
Hepatitis, Aids, TB ______
Liver problems ______
Polio ______
Epilepsy or seizures ______
Bowls or colon ______
Bladder problem ______
Kidney problem ______
Balance problem ______
Numbness or tingling ______
Blackout or fainting ______
13)Please list all past surgeries and hospitalization:
Surgery/hospitalization DatePhysician
______
______
______
14)Have you ever had problems with general anesthesia? YES NO
15)Do you drink alcohol? YES NOIf yes, how much per week? ______
16)Do you smoke? YES NOIf yes, how much per week? ______
How long have you smoked? ______
17)Marital Status: Single Married Divorced/Separated Widowed
18)Do you:
YESNO
Have children How many______
Live alone If no, with whom______
Use a special diet Describe______
Use recreational drugs Describe______
Exercise regularly How often______
19)Sports/Hobbies: ______
20)Family History
Member Alive Deceased Age Health Status Cause of Death
Father ______
Mother ______
Sibling ______
Sibling ______
Sibling ______
21)How tall are you? ______How much do you weigh? ______
Patient Signature______Date ______
Thank you for taking the time to complete this information!
Reviewed by: ______Date: ______
Page 1 of 4 -- Patient Intake Form – Knee – Howard J. Luks, MD -- updated 06/06