West Palm Beach, FL Knee Pain Assessment

Section 1 of 3

1. Which knee is causing you problems?

Left Right Both

2. How would you describe your knee pain?

3. How long have you had this pain?

4. On a scale of 1-5, how much worse has your knee pain gotten recently?

5. Have you gone through physical therapy for treatment of your knee pain?

Yes No

6. Have you received injections into your knee joint as part of your treatment for knee pain?

Yes No I do not know

7. If you have received knee injections, when did they start?

8. Have you been told or are you concerned that you may have a sensitivity or be allergic to certain types of metal?

Yes No I do not know

Section 2 of 3

9. How long can you walk, with or without cane or walking device, before knee pain becomes an issue?

10. Does knee pain cause you to limp?

11. In a month, how many nights does knee pain affect your sleep?

12. How much does your knee pain limit your daily activities?

13. How often do you feel like your knees are unstable or may fail to support you?

14. Can you perform activities such as shopping and housekeeping on your own?

Section 3 of 3

15. Please list your top 4 responses to the following question:
After surgery, I want a knee replacement that:

Most important:

Next most important:

Third most important:

Fourth most important:

16. What do you miss most because of knee pain?

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Jonathan Shaw , MD Knee Pain Assessment

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