Please confirm your full name
*
Please confirm your phone number
*
What is your best email?
*
If 10 means you can't sleep and 1 means you barely notice, what is the level of your pain?
*
0
1
2
3
4
5
6
7
8
9
10
Which of these activities cause you pain? (check all that apply)
*
Walking
Stairs
Squatting/bending
Standing/Cooking
Running
Bent knee/sitting for long periods of time
Have you already had a knee replacement?
*
Yes
No
(If Yes) Which knee was replaced?
*
Left
Right
Both
Have you had any injections in your knee(s) in the past 6 months?
*
Yes
No
(If Yes) What type of injection?
*
Do you currently have health insurance?
*
Yes
No
Who is your major insurance provider?
*
Do you have supplemental insurance? (If yes, type it below)
*
No