Knee Symptom Form

The knee symptom form and Examination form are to help General practitioners, Sports Physicians and Physiotherapists refer patients with adequate information. The information is also designed to help Orthopaedic trainees/ residents learn a systematic examination technique. This page is not for patients to self refer themselves to my clinic.

Please Contact my Secretary Ms Christine Kirkham on 07784476138

Please provide as much information as possible

 

Your Name*

Age*

Email*

Knee

History

Symptom Start Date

Injury Description

Felt pop at Injury

Walking Distance

Night Pain

Pain on stair climbing or walking down inclines

Swelling

Giving Way

When and how many times

Locking

Patella Dislocations

How Often

Treatment

Previous Surgery

Past Medication

Occupation/Leisure Activities/Tegner Score