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Please select only the part of the body that you are scheduled to be evaluated for today
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New Yes / No
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Shoulder
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Knee
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Hip
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Foot & Ankle
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Elbow
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New Yes / No
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Shoulder History
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New Yes / No
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Dominant Arm?
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Which shoulder is symptomatic?
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What type of shoulder symptoms are you having?
• • •
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What caused your pain?
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Have your symptoms been:
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Does your shoulder hurt:
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Are you taking any medications for your symptoms?
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Is so, what medication (with dosage and frequency)?
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Have you injured the symptomatic shoulder in the past?
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If so, when did it occur and what was the diagnosis?
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Please indicate all formal treatment(s) you have received thus far:
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MRI?
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Date and name of facility?
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Physical Therapy?
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Did this treatment help?
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How many sessions?
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New Yes / No
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Cortisone Injection(s)
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Did this treatment help?
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How many and date of last injection?
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New Yes / No
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Other Treatments
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Comment
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Did this treatment help?
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New Yes / No
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ASES Assessment
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Placeholder
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How bad is your pain today?
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New Yes / No
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Select your ability to do the following:
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Put on a coat (Left arm)
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Put on a coat (Right arm)
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Sleep on your painful / affected side (Left arm)
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Sleep on your painful / affected side (Right arm)
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Wash back/do up bra in back (Left arm)
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Wash back/do up bra in back (Right arm)
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Manage toileting (Left arm)
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Manage toileting (Right arm)
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Comb hair (Left arm)
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Comb hair (Right arm)
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Reach a high shelf (Left arm)
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Reach a high shelf (Right arm)
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Lift 10 lbs. above shoulder (Left arm)
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Lift 10 lbs. above shoulder (Right arm)
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Throw a ball overhand (Left arm)
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Throw a ball overhand (Right arm)
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Do usual work (Left arm)
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Do usual work (Right arm)
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Please list what your usual work involves
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New Yes / No
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Do usual sport (Left arm)
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Do usual sport (Right arm)
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Please list what your usual sport involves
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New Yes / No
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Knee History
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Placeholder
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Which knee is symptomatic?
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If both, which one hurts more?
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What types of symptoms are you having?
• • •
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What caused your symptoms?
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When did your symptoms begin?
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Have your symptoms been:
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Does your knee hurt during:
• • •
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New Yes / No
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Are you taking any medications for your symptoms?
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Is so, what medication (with dosage and frequency)?
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Have you injured the symptomatic knee in the past?
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If so, when did it occur and what was the diagnosis?
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Please indicate all formal treatment(s) you have received thus far:
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Knee MRI?
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Date and name of facility?
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Physical Therapy (Knee)?
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Did this treatment help?
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How many session?
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New Yes / No
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Knee Injection(s)
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Did this treatment help?
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How many and date of last injection?
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New Yes / No
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Other Treatments (Knee)
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Comment
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Did this treatment help?
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New Yes / No
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Lysholm Knee Scoring Scale
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Placeholder
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Section 1 – Limp
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Section 2 – Using cane or crutches
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Section 3 – Locking sensation in the knee
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Section 4 – Giving way sensation from the knee
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Section 5 – Pain
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Section 6 – Swelling
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Section 7 – Climbing stairs
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Section 8 – Squatting
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2000 IKDC Subjective Knee Evaluation
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Symptoms
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New Short Text Field
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Grade symptoms at the highest activity level at which you think you could function
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without significant symptoms, even if you are not actually performing activities at this level.
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What is the highest level of activity that you can perform without significant knee pain?
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During the past 4 weeks, or since your injury, how often have you had pain?
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If you have pain, how severe is it?
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What is the highest level of activity that you can perform without significant swelling in your knee?
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During the past 4 weeks, or since your injury, did your knees lock or catch?
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What is the highest level of activity that you can perform without significant giving way in your knee?
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Sports Activities
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New Short Text Field
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What is the highest level of activity that you can participate in on a regular basis?
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How does your knee affect your ability to:
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Going up stairs
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Going down stairs
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Kneel on the front of your knee
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Squat
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Sit with your knee bent
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Rise from a chair
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Run straight ahead
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Jump and land on your involved leg
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Stop and start quickly
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New Yes / No
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Function
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New Short Text Field
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Function prior to knee injury (no points for this category)
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Current function of your knee (points recorded for this category)
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Hip History
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New Short Text Field
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Which hip is symptomatic?
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If both, which one hurts more?
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What types of symptoms are you having?
• • •
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What caused your symptoms?
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When did your symptoms begin?
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Have your symptoms been:
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Have you noticed if one leg is shorter than the other?
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Are you taking any medications for your symptoms?
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Is so, what medication (with dosage and frequency)?
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Have you injured the symptomatic hip in the past?
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If so, when did it occur and what was the diagnosis?
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Please indicate all formal treatment(s) you have received thus far:
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Hip MRI?
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Date and name of facility?
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Physical Therapy (Hip)?
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Did this treatment help?
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How many sessions?
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New Yes / No
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Hip Injection(s)
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Did this treatment help?
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How many and date of last injection?
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New Yes / No
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Other Treatments (Hip)
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Comment
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Did this treatment help?
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New Yes / No
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Foot and Ankle History
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New Short Text Field
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Which foot/ankle is symptomatic?
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If both, which one hurts more?
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What types of symptoms are you having?
• • •
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What caused your symptoms?
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When did your symptoms begin?
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Have your symptoms been:
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Are you taking any medications for your symptoms?
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Is so, what medication (with dosage and frequency)?
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Have you injured the symptomatic foot/ankle in the past?
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If so, when did it occur and what was the diagnosis?
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Please indicate all formal treatment(s) you have received thus far:
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Foot/Ankle MRI?
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Date and name of facility?
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Physical Therapy (Foot/Ankle)?
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Did this treatment help?
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How many session?
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New Yes / No
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Foot/Ankle Injection(s)
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Did this treatment help?
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How many and date of last injection?
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New Yes / No
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Other Treatments (Foot/Ankle)
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Comment
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Did this treatment help?
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New Yes / No
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Elbow History
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New Short Text Field
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Dominant Arm?
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Which elbow is symptomatic?
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If both, which one hurts more?
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What type of elbow symptoms are you having?
• • •
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What caused your pain?
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When did your symptoms begin?
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Have your symptoms been:
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Does your elbow hurt:
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Are you taking any medications for your symptoms?
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Is so, what medication (with dosage and frequency)?
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Have you injured the symptomatic elbow in the past?
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If so, when did it occur and what was the diagnosis?
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Please indicate all formal treatment(s) you have received thus far:
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Elbow MRI?
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Date and name of facility?
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Physical Therapy (Elbow)?
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Did this treatment help?
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How many sessions?
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New Yes / No
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Cortisone Injection(s) (Elbow)
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Did this treatment help?
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How many and date of last injection?
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New Yes / No
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Other Treatments (Elbow)
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Comment
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Did this treatment help?
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New Yes / No
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Review of Systems
• • •
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New Yes / No
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Medical/Surgical History
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New Short Text Field
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Who referred you to the office today?
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Primary Care Doctor Name
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Pharmacy Name/Address
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Pharmacy Phone Number
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Past Medical History
• • •
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Other Past Medical History
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Past Surgical History (and dates)
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Family Medical History
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New Short Text Field
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What medical conditions run in your family?
• • •
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Additional Family Medical History
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Occupational/Social History
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New Short Text Field
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Tobacco Use
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Alcohol (drinks per week)
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Caffeine (drinks per day)
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Drug Use
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Occupation
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Employer
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Medications and Allergies
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New Short Text Field
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Medications
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Allergies (and reaction)
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Vitals Signs
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New Short Text Field
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Height
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Weight
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