SPORTS MEDICINE DATA COLLECTION FORM � GENERAL # 16

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SPORTS MEDICINE DATA COLLECTION FORM � GENERAL # 16 Powered By Docstoc
					                                                               ICRS Joint Pathology and Surgery Evaluation Data Collection Form


PATIENT DEMOGRAPHICS AND CLINICAL HISTORY FORM # 1
                  [I.D. STICKER HERE]
Patient Name:                                                         Study ID:
Patient ID:                                                                  Male       Female
Date of Birth:                                                        Weight:_________ Height:_________
Surgeon:
                                                                      Address:


Phone:                                                                Email Address:
Date of Exam:                                                         Referring Dr:


Is this a workers compensation case                  Yes      No
Is your opposite knee or joint                       Normal         Nearly normal             Abnormal       Severely abnormal
Any other joint problems (tick those affected)       Hips           Ankles                    Shoulders      Elbows
                                                     Hands          Feet                      Spine          Neck
Were your onset of symptoms                          Sudden         Gradual
If caused by injury what was the date            ____/________/________
What was the cause of the injury                     Sport          Car accident              Motor bike     Other accident      No known injury
What type of work do you do                          Office         Domestic duties           Non manual work but involves walking
                                                     Light manual   Heavy manual
What was your activity level before your joint problem              High level competitive sports            Well trained, frequent sports
                                                                    Sports sometimes                         No sport
What is or are your main sport/s (if sporting) : ______________________________________
What is your current functional status (due to your injury:
   I can do everything                        nearly everything                         I am restricted, many things are not possible
   I am severely restricted in everything I do


Surgeon to input                           ( Use IKDC Surgeon form for more extensive clinical examination input)

Number of previous surgeries _________
Location/TYPE:          Meniscus           Excision of loose bodies                 Chondral repair        Synovectomy
(multi)                 ACL repair         Other ligament                           Osteotomy              Exploratory arthroscopy
                        Patellar           Extensor mechanism repair                Tendon repair          Other         Details unknown


Pre existing conditions _________________________________________________________________________________________

Kellgren Lawrence grading          0             1            2          3               4
MRI taken               Yes        No
MRI findings            1          2             3            4          5

Notes:




[NB: Unless stated “multi”, pick only one of each]



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