Knee Pain Questionnaire

1. Which knee hurts? L R Both (please circle one)

2. How long has your knee hurt? ________________________________

3. Was the onset of pain gradual or was there an injury? _______________________

If injury, please describe briefly: ________________________________________

_________________________________________________________________

_________________________________________________________________

4. Does your knee swell? _________

5. Does your knee catch, lock or snag? _____________________________________

6. Does your knee give away? __________

7. Do you have pain at rest? __________

8. Do you have pain on weight bearing? ___________

9. Do stairs exacerbate your pain? _____________

10. Have you had any of the following treatments: (please check the ones that apply)

_____Anti-inflammatory medication
_____Steroid medications
_____Physical Therapy
_____Injections to the knee
_____Prior surgery

11. Is your knee pain made worse by: (please check the ones that apply)

_____ Kneeling
_____ Stooping
_____ Bending
_____ Crawling
_____ Getting up from a chair

______________________________________________

FOR PHYSICIAN USE
ROM: _____________________________________

Stability: varus_____ valgus_____ lachman's_____ drawer_____ post surg_____

Effusion: _________________________________

Tenderness: MJL_____ LJL_____ Patellar_____

Patellar mechanics: _________________________