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The Orthopedic Center at Princeton Community Hospital
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Ankle
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Dr. Branson Knee Appointment Form
Name
*
First
Last
Email
Phone
*
Knee
Right
Left
Problem Onset
Gradual
Sudden Onset
Result of an injury
Onset Date
Date Format: MM slash DD slash YYYY
Symptoms
Loss of motion/stiffness
Instability/giving out
Locking
Deformity
Limp
Unable to bear the weight
Limited ability to walk
Night time pain
Check all that apply:
I have been told I have:
Arthritis
Torn ligament
Dislocation
Torn Cartilage (meniscus)
Fracture
Infection
Location of PAIN:
1
2
3
4
5
6
7
8
9
10
11
12
Please select the numbers.
History:
Pain, Swelling, loss of motion, injury: Tell us what happened and what is going on in your own words:
Prior Problems:
Knee injury
Rheumatoid arthritis
Osteoarthritis
Fracture
Check those that apply:
Prior Studies:
Xray
MRI
CT Scan
Other Tests:
Check those that apply:
Other Tests:
PLEASE BRING REPORTS AND DISC of studies with you to your appointment.
Hospitals do not send us the images. Doctors will review the images and reports. If you do not bring the studies and reports, a complete evaluation of your knee may be delayed.
Surgery
Date
Operation
Helped or did not help?
Physical Therapy
Number of Weeks
Helped or did not help?
Injections
Date
Helped or did not help?
NSAID (anti inflammatory medication)
Helped or did not help?
Pain Medication
If you have prior surgeries, please bring copies of the operative note, records / reports with you to your appointment. If you have hardware or implants in your knee, please request a copy of the IMPLANT RECORD from the hospital where surgery was performed. The Implant record should include the Manufacturer and type of implant.
Other notes for doctor:
