Knee Patient Intake Form

Welcome!

It is our pleasure to serve you and we look forward to your visit. In order to better serve you, we ask your time to complete the following evaluation questionnaire. Simply, point and click on the appropriate response for your condition. These answers will help your Doctors better understand your condition and guide treatments throughout your recovery.

Thank you for choosing Dr. Meininger for your Orthopaedic needs.
Alexander K. Meininger, MD

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    General Health Questions

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    Vigorous activities, such as running, lifting heavy objects, participating in strenuous sports
    Moderate activities, such as moving a table, pushing a vacuum cleaner, bowling or playing golf
    Lifting or carrying groceries
    Climbing several flights of stairs
    Climbing one flight, or 10 stairs
    Bending, kneeling or stooping
    Walking more than a mile
    Walking several hundred yards
    Walking 100 yards
    Bathing or dressing yourself
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    Cut down on the amount of time you spent on work or other activities
    Accomplished less than you would like
    Were limited in the kind of work or other activities
    Had difficulty performing the work or other activities (for example, it took extra effort)
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    Cut down on the amount of time you spent on work or other activities
    Accomplished less than you would like
    Did work or other activities less carefully than usual
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    Did you feel full of life?
    Have you been very nervous?
    Have you felt so down in the dumps that nothing could cheer you up?
    Have you felt calm and peaceful?
    Did you have a lot of energy?
    Have you felt downhearted and depressed?
    Did you feel worn out?
    Have you been happy?
    Did you feel tired?
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    I seem to get sicker a little easier than other people
    I am as healthy as anybody I know
    I expect my health to get worse
    My health is excellent
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    Knee Specific Questions

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    Go up stairs
    Go down stairs
    Knee on the front of your knee
    Squat
    Sit with your knee bent
    Rise from a chair
    Run straight ahead
    Jump and land on your involved leg
    Stop and start quickly
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