Knee Pain Intake Form

Knee Pain Intake Form

Complete this before your appointment and your provider can be better prepared during their time with you.
Name

First NameLast Name
Nickname
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birth Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Email address:
example@example.com
Cell Phone
Preferred Method of Contact
Marital Status
Sex
Spouse's Name
Current or Previous Work
Your Occupation
Retired?
In Case of Emergency Contact
Phone Number
How did you hear about our office?
Tell Us About Your Past Health

Please check all that apply
What kind of problem(s) are you having?
When did this begin?
On a Scale of 0-10 (0=best, 10=worst), how would you rate your symptoms
How would you describe your symptoms?
What makes it better?
What makes it worse?
Are your conditions worse at night?
Is this condition interfering with any of the following?
Please check all that apply - choose multiple
Please list below any serious medical conditions you have had
List individually with dates if possible
List any BACK, KNEE, or LEG SURGERIES you've had
Current Pain Levels
How would you describe your average knee pain over the past week? (0=no pain 10=worst pain possible)
Which of the following is true for your condition?
List any daytime activities (you used to be able to do when you were feeling better) that are now limited.
List the main goals that you would like to accomplish.
Please indicate what you consider to be an acceptable level of pain after completion of the treatment (if you have to accept some pain.) 0=no pain 10=worse pain possible
Please list any medication and/or vitamins/supplements you are currently taking.
Informed Consent and Insurance Information

Informed consent for treatment/diagnostic Testing

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the doctor's office of any changes in my medical status. I certify that I am the patient or legal guardian of the above listed patient. I authorize this office and its staff to examine and treat my condition as the medical professionals see fit, including having diagnostic x-ray examination if necessary.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
For Females: Verification of Pregnancy Status
**This is to certify that, to the best of my knowledge, I am not pregnant and give my persmission to have diagnostic x-ray if necessary** (if you are unsure of your pregnancy status, it is very important that you inform your care provider prior to any diagnostic imaging.)
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Release of Information
This is confidential record of my medical history and pertinent personal information. The doctor/nurse practitioner reserves the right to discuss this information with medical and allied health professionals per this informed consent. Copies of this record can only be released by your written authorization. Copies of this record can only be released by your written authorization.
Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Insurance Information
Primary Insurance Company
Subscriber ID
Group ID
Name and Date of Birth of Primary Account Holder
Insurance Card (back)

Browse Files

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Insurance Card (front)

Browse Files

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Should be Empty:

Knee Pain Intake Form

Tell Us About Your Past Health

Please list below any serious medical conditions you have had

Current Pain Levels

For Females: Verification of Pregnancy Status

Release of Information

Insurance Information