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Download Knee Evaluation - Daniel Haber, MD
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DANIEL F. HABER, M.D. 221 E.HACIENDA AVE. SUITE C CAMPBELL, CA 95008 408-374-5700 KNEE PATIENT EVALUATION FORM Please answer all questions completely NAME ________________________________________________ CHART # __________________ AGE: _________________ SEX: _____________________ WHICH KNEE: ___________________ HOW LONG HAVE YOU HAD SYMPTOMS ______________ TODAY’S DATE _____________ DATE THIS PROBLEM BEGAN ______________________________________________________ 1. MY MAJOR COMPLAINT IS (check all that apply) pain dull ache loss of motion swelling grinding giving out locking other (please explain) ___________________________________________________ 2. DID THIS PROBLEM START: (check all that apply) gradually vehicle accident suddenly don't know while playing sports - which sport__________________________________________ while at work IF YOU HAVE BEEN EXPERIENCING PAIN, PLEASE ANSWER THIS SECTION. IF NOT, PLEASE GO TO QUESTION 8. 3. THE PRIMARY LOCATION OF PAIN IS: (check those that apply) kneecap back throughout the knee inner side outer side deep inside 4. WHEN DOES THE AFFECTED KNEE HURT? (please check one) infrequently constantly when active 4A. DOES THE AFFECTED KNEE HURT WHEN YOU ARE RESTING? yes no 5. DOES THE PAIN IN THE AFFECTED KNEE OCCUR AT NIGHT? yes no 5A. WHEN THIS PAIN OCCURS, DOES IT AWAKEN YOU? yes no 6. WHEN IS THE PAIN MADE WORSE? (please check those that apply) sitting getting up standing running walking climbing stairs during physical exercise 1 of 4 DANIEL F. HABER, M.D. 221 E.HACIENDA AVE. SUITE C CAMPBELL, CA 95008 408-374-5700 7. THE PAIN IS RELIEVED BY: (check those that apply) nothing rest moving the knee heat therapy activity cold therapy medicine - if so, what kind? _________________ _ 8. IS THE AFFECTED KNEE EVER SWOLLEN? (check those that apply) never infrequently only after exercise or use constantly at the time of the original injury, but not since then 9. ARE THERE ANY GRATING OR GRINDING NOISES OR SENSATIONS IN THE JOINT? (please check those that apply) none when getting up from a chair when walking when climbing stairs when descending stairs when I do deep knee bends 10. WHEN DOES YOUR KNEE LOCK (GET STUCK)? never frequently or occasionally at first, not now continually 11. WHEN KNEE GIVES OUT OR BUCKLES IT FEELS LIKE: (check those that apply) does not buckle entire Knee shifts kneecap shifts something inside the knee shifts 12. WHAT IS THE RANGE OF MOTION IN YOUR AFFECTED KNEE? same as ever unable to fully bend or flex the joint unable to fully straighten the joint 13. MOBILITY OF THE JOINT: able to walk normally walk with a limp 14. WHAT ACTIVITIES ARE YOU UNABLE TO DO? (please check those that apply) walk - how far? climb not affected 1 block jump run greater than 1/2 mile squat 15. ARE YOU USING ANY WALKING AIDS? none wheelchair cane brace 16. HAVE YOU SEEN A PHYSICIAN FOR THIS PROBLEM? crutches walker YES NO DOCTOR: ______________________________________________________________________ ADDRESS: _____________________________________________________________________ DIAGNOSIS: ____________________________________________________________________ TREATMENT: __________________________________________________________________ 2 of 4 DANIEL F. HABER, M.D. 221 E.HACIENDA AVE. SUITE C CAMPBELL, CA 95008 408-374-5700 TYPE OF DOCTOR: ______________________________________________________________ 17. WERE YOU TREATED AT AN EMERGENCY ROOM FOR THIS PROBLEM? YES NO HOSPITAL ______________________________________________________________________ ADDRESS ______________________________________________________________________ 18. DID YOU HAVE X-RAYS TAKEN FOR THIS PROBLEM? If yes, please list below: DATE LOCATION ______________________ ______________________ ______________________ ______________________ 19. DID YOU HAVE AN ARTHROGRAM? (dye test)? YES NO RESULTS _______________________ _______________________ YES NO If yes, please list below: DATE LOCATION ______________________ ______________________ RESULTS ______________________ ______________________ _______________________ _______________________ 20. DID YOU HAVE AN ARTHROSCOPY OR ARTHROSCOPIC SURGERY PERFORMED ON THE AFFECTED KNEE? (looking into the joint) YES NO If yes, please list below: DATE LOCATION ______________________ ______________________ RESULTS ______________________ ______________________ _______________________ _______________________ 21. DID YOU HAVE OPEN SURGERY ON THE KNEE JOINT? YES If yes, please list below: DATE DOCTOR TYPE RESULT NO COMPLICATION ______________ _______________ _______________ _______________ _______________ ______________ _______________ _______________ _______________ _______________ 22. DO YOU HAVE ANY OF THE FOLLOWING MEDICAL PROBLEMS? If yes, please list below: YES NO heart disease high blood pressure lung disease diabetes rheumatoid arthritis other arthritis inherited disease gout stomach ulcer bleeding tendency circulation problems cancer other (describe) ________________________________________________________ 23. HAVE YOU BEEN UNDER A DOCTORS CARE IN THE LAST TWO YEARS? YES NO If yes, please list below: DOCTOR: ____________________________ ADDRESS: _______________________________ 3 of 4 DANIEL F. HABER, M.D. 221 E.HACIENDA AVE. SUITE C CAMPBELL, CA 95008 408-374-5700 REASON: ______________________________________________________________________ 24. WHAT MEDICATIONS ARE YOU CURRENTLY TAKING? MEDICATION _______________________________________________ _______________________________________________ DOSAGE _______________________________ _______________________________ 25. HAVE YOU TAKEN ANY OF THE FOLLOWING MEDICATIONS WITHIN THE PAST SIX MONTHS? YES / NO / / / / / Cortisone pills or shots High blood pressure pills Water pills Heart medicine Insulin 26. PLEASE LIST ALL KNOWN ALLERGIES AND YOUR REACTION: ALLERGY _______________________________________________ _______________________________________________ _______________________________________________ REACTION _______________________________ _______________________________ _______________________________ 27. PLEASE LIST ANY SURGERIES YOU HAVE HAD ALONG WITH ANY COMPLICATIONS THAT MAY HAVE OCCURRED: SURGERY _______________________________________________ _______________________________________________ _______________________________________________ COMPLICATIONS _______________________________ _______________________________ _______________________________ 28. PLEASE RATE YOUR OVERALL LEVEL OF PHYSICAL HEALTH: excellent very good good fair poor HEIGHT: ____________________________ WEIGHT: ____________________________ RIGHT HANDED DO YOU SMOKE? LEFT HANDED YES BOTH NO 29. WHO REFERRED YOU TO US FOR THIS EVALUATION AND CARE? physician trainer found the office in the yellow pages former patient coach word of mouth (includes other patients) 4 of 4
