The Bridge Chiropractic
Knee Pain Program Questionnaire
First Name
*
Last Name
*
Phone
*
Email
*
How Can We Help
How often does your knee pain show up?
Only after long activity
A few days a week
Daily
Constant / limits my life
Which of these have you stopped or cut back on because of your knee? (Select all that apply)
Walking / stairs
Exercise or sports
Playing with kids or grandkids
Work or daily chores
None yet
What have you already tried? (Select all that apply)
Rest / ice / meds
PT or exercise
Injections
Surgery was suggested
Nothing yet
Have you been told any of the following?
"Bone-on-bone"
Arthritis / degeneration
Meniscus tear
None of these / not sure
If there were a way to improve movement and reduce pain without surgery or injections, would you want to explore it?
Yes, ASAP
Possibly - need more info
Not right now