BPA-Application-for-Knee-Pain-Treatment-v2 (5) (1)

Application for Knee Pain Treatment (Please Print Clearly)

Please fill out the application entirely and legibly. We need all information for insurance purposes.
Date

MonthDayYear
Date
Name
Social Security#
Date of Birth

MonthDayYear
Date
Age
Sex
Marital Status
# of children
Address
City
State
Zip
Phone
Format: (000) 000-0000.
Email
example@example.com
Spouse's Name
Phone Number
Format: (000) 000-0000.
Your Occupation
Retired?
Current or Previous Work
Clerical
Light Labor
Moderate Labor
Heavy Labor
In Case of Emergency Contact
Phone Number
Format: (000) 000-0000.
TELL US ABOUT YOUR PAST HEALTH:
Lower Back PainDiabetes AICHigh CholesterolLeg or Foot Pain /NumbnessHand ProblemsShinglesSpinal FracturesNeuropathyKnee SurgerySpinal StenosisHeart AttackKidney issues or DialysisSpinal ArthritisHeart ProblemsGoutSciaticaHigh/Low Blood PressureHip SurgeryVascular Leg ProblemsLeg FracturesNeck PainVascular SurgeryJoint ReplacementHerniated DiscStrokeFoot Surgery
PLEASE LIST ANY MEDICATION AND/OR VITAMINS YOU ARE CURRENTLY TAKING OR ATTACH MED LIST:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
PLEASE LIST BELOW ANY SERIOUS MEDICAL CONDITIONS YOU HAVE HAD:
NAME OF YOUR PRIMARY CARE PHYSICIAN
YesNo
PLEASE LIST BELOW ANY BACK, KNEE, OR LEG SURGERIES YOU'VE HAD?
YesNo
WHEN?
YesNo
WHAT?
YesNo
AROUND WHAT TIME?
WHAT KIND OF PROBLEM(S) ARE YOU HAVING?
ON A SCALE, HOW WOULD YOU RATE YOUR SYMPTOMS (10 is the worst)
WHEN DID THIS BEGIN
WHAT MAKES IT BETTER?
WHAT MAKES IT WORSE
Stabbing-SharpElectric-ShocksColdTinglingSwellingBurningStingsAcheNumbnessTirednessCramping
SleepWorkDaily RoutineChoresWalkingStandingShopping
How would you describe your average knee pain over the past week (1-10)? (1 = no pain, 10=worst pain possible)
Please indicate what you consider to be an acceptable level of pain after completion of the treatment, if you have to accept some pain (1-10)?
It's getting better on its ownIt's staying the sameIt's getting worse as time goes by
List any daytime activities (you used to be able to do when you were feeling better) that are now limited
List the three main "health goals" that you would like to accomplish:
1.
2.
3.
A. I hereby authorize release of any medical information necessary to evaluate my case or process any future claims. B. I authorize payment of any medical benefits from third parties for any future charges submitted to be paid directly to this office We invite you to discuss with US any questions regarding our services and or fees. The best health services are based on a friendly, mutual understanding between the provider and patient.

Iunderstand the above information and guarantee this form was completed correctly to the best of my knowledge. I understand it is my responsibility to inform this office of any changes in my medical or insurance status.
Signature

Clear
Date

MonthDayYear
Date
HOW DID YOU HEAR ABOUT OUR OFFICE?
WALKING SCALE QUESTIONNAIRE
These questions ask about limitations to your walking due to knee pain during the past 2 weeks. For each statement please circle the one number that best describes your degree of limitation. Please check you have circled one number for each question. Please hand this to the doctor at the start of your consultation.
IN THE PAST 2 WEEKS, HOW MUCH HAS YOUR KNEE PAIN
NOT AT ALL

Type a question

Rows	NOT AT ALL	A LITTLE	MODERATELY	QUITE A BIT	EXTREMELY
LIMITED YOUR ABILITY TO WALK?
LIMITED YOUR ABILITY TO RUN?
LIMITED YOUR ABILITY TO CLIMB UP OR DOWN STAIRS?
MADE STANDING WHEN DOING THINGS MORE DIFFICULT?
LIMITED YOUR BALANCE WHEN STANDING OR WALKING?
LIMITED HOW FAR YOU ARE ABLE TO WALK?
INCREASED THE EFFORT NEEDED FOR YOU TO WALK?
MADE IT NECESSARY FOR YOU TO USE SUPPORT WHEN WALKING INDOORS (E.G. HOLDING ON TO FURNITURE, USING A CANE, ETC?
MADE IT NECESSARY FOR YOU TO USE SUPPORT WHEN WALKING OUTDOORS (E.G. USING A CANE OR WALKER, ETC?
SLOWED DOWN YOUR WALKING?
AFFECTED HOW SMOOTHLY YOU WALK?
MADE YOU CONCENTRATE ON WALKING?

KNEE PAIN PROGRAM QUALIFICATION QUESTIONNAIRE (PLEASE ANSWER ALL THE FOLLOWING QUESTIONS BY CIRCLING ONE ANSWER PER QUESTION) THANK YOU FOR COMPLETING THIS QUESTIONNAIRE.
RightLeftBoth
YesNo
YesNoUnsure
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
Should be Empty:

WALKING SCALE QUESTIONNAIRE

IN THE PAST 2 WEEKS, HOW MUCH HAS YOUR KNEE PAIN

NOT AT ALL