1
Knee Evaluation Form Date________
Pease answer/circle all questions in patient section
PATIENT SECTION
Name_________________________
Age ____ Sex M F
Involved Knee Right Left Both – Right or Left Worse
Date Injured_______
Describe Injury
Did you feel/hear a pop?
Swelling after injury (how much, how soon after)?
If not injured, when did problem start?
What do think caused the problem?
Do you have (please circle) Any injections (what kind, when)?
Swelling
Locking
Clicking/catching What makes pain worse?
Loose/unstable feeling knee
Stiffness/loss of motion
Weakness List previous knee injuries
Pain is located on which part of the List previous treatment (Physical
knee? Therapy, Brace, Orthotics)
Inside
Front
Back
Outside
What makes pain worse? How severe is the pain?
0 1 2 3 4 5 6 7 8 9 10
None Extreme
What helps relieve pain?
What make pain better?
List previous surgery, dates, surgeon
Any medications taken for this?
2
PATIENT SECTION PHYSICIAN SECTION
Varus Valgus Neutral
List sports/recreational activities ROM R ___-___-____ L___-___-____
Q> R____ L____
Effusion R____ L____
Patellar Crepitus R____ L____
Patellar Comp R____ L____
Patellar Inhib R____ L____
Do you have difficulty with? (Circle all Patellar App R____ L____
that apply): Patellar Glide R____ L____
Walking MJLT R____ L____
Standing LJLT R____ L____
Sitting McMurray R____ L____
Standing after being seated Lachman R____ L____
Walking down stairs AD R____ L____
Walking up stairs PS R____ L____
Squatting SAG R____ L____
Kneeling PD R____ L____
Sleeping Reverse PS R____ L____
Cutting/Pivoting/Twisting Dial R____ L____
ERR R____ L____
How many blocks/miles can you walk Varus 0 R____ L____
comfortably? Varus 30 R____ L____
Valgus 0 R____ L____
Valgus 30 R____ L____
What do you expect from treatment of Thigh Circ R____ L____
your problem? DNV R____ L____
X-Ray
Occupation ___________________
Is this a work- related injury? Y N MRI
Is there litigation involved? Y N
IMP
Plan MRI
Please Stop Here NSAID
PT
Orthotics
Brace
Viscous
Surgery