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Osteoarthritis of the Knee Screening Form

Patient Name:
DOB:
Patient Email:
Contact Number:
WOMAC Score: Rate the activities in each category according to the following scale of difficulty:
0 = None
1 = Slight
2 = Moderate
3 = Very
4 = Extremely
0
1
2
3
4
I. Pain
1
Walking
2
Stair climbing
3
Nocturnal (Pain at night time)
4
Rest
5
Weight-bearing (Standing)
II. Stiffness
1
Morning stiffness
2
Stiffness occurring later in the day
III. Physical Function
1
Descending stairs
2
Ascending stairs
3
Rising from sitting
4
Standing
5
Bending to floor
6
Walking on a flat surface
7
Getting in/out of car
8
Going shopping
9
Putting on socks
10
Lying in bed
11
Taking off socks
12
Rising from bed
13
Getting in/out of bath
14
Sitting
15
Getting on/off toilet
16
Heavy domestic duties
17
Light domestic duties
Total from each column:
0
0
0
0
0
Total ( 0 to 96 )
0
Additional Information
Right Knee
Left Knee
Yes
No
Yes
No
Do you have knee pain?
From 0 to 10, what is your knee pain level? (0: No pain, 10: Severe pain)
Do you take medication for knee pain? (Mark for each knee)
Do you still have knee pain when you take pain medication?
How long have you been taking pain medication for knee pain?
Have you previously had a knee joint injection?
Did the knee joint injection help?
Did you have to repeat the knee joint injection?
How often do you repeat the knee joint injection?
Have you previously had knee surgery?
Have you had a knee replacement?
Have you been told you are not a candidate for knee surgery?

We offer an alternative to traditional surgeries which can have long recovery timesand higher rates of complications for many common conditions such as arthritis of the knee, BPH, and hemorrhoids. We bring awareness to both patients and primary care physicians about PAD and alternative minimally invasive treatment options.

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