GAE Clinic Visit
Patient's First Name
Patient's Last Name
Date of birth
Which knee is experiencing pain
Left
Right
Both
Location of pain?
Inside of knee
Outside of knee
Front
Back
How would you describe your knee pain
Stiffness
Dull / Aching
Sharp / Stabbing
Burning
Pins and Needles
Tender to Touch
GAE How long have you been experiencing knee pain?
How has your knee pain affected your daily activities
Walking
Climbing stairs
Descending stairs
Sitting for long periods
Playing with Grandchildren
Standing from a seated position
Work activities
Activities of daily living
Pickle Ball
Golf
Others
Have you seen an orthopedics doctor
Yes
No
Have you had any of these treatments
Steroid Injections
Euflexxa/Rooster Comb/Gel injection
PRP Injections
Stem Cell
Physical therapy
Exercise
Ice
Medications
Brace
Cane
Walker
When was your last Injection
Please Specify
Have you had a previous injury to the knee
Yes
No
Specify type and time
Have you ever had an X-ray of your knee
Yes
No
When
Where
Have you had previous surgery
Meniscus surgery
Ligament surgery
Cartilage procedure
Contralateral joint replacement
Other
Please Specify
How often are you aware of your knee problem?
Never
Monthly
Weekly
Daily
Constantly
Have you modified your life style to avoid potentially damaging activities to your knee?
Not at all
Mildly
Moderately
Severely
Totally
How much are you troubled with lack of confidence in your knee?
Not at all
Mildly
Moderately
Severely
Extremely
In general, how much difficulty do you have with your knee?
None
Mild
Moderate
Severe
Extreme
Please rate how bothersome your symptoms are on a scale from 0 to 5, where 0 means “not bothersome” and 10 means “extremely bothersome.
(0) Not Bothersome at all
(1)
(2)
(3)
(4)
(5) Extremely Bothersome
Grading
Vein and Artery Health
I have visible varicose or spider veins
I feel heaviness, swelling, or aching in my legs
I experience calf pain during walking or physical activity
I have heel pain when I first get out of bed in the morning
Yes
No
Reproductive and Urinary Health For Men
I wake up at night to urinate
I have trouble starting or maintaining urine flow
Reproductive and Urinary Health For Women
My periods are long, heavy, or painful
I have ongoing pelvic pain, especially when standing or during my period
I have a history of uterine fibroids
Submit
