Knee - Plano Orthopedic & Sports Medicine Center

Name

First

Last

Email

Primary Phone

Mobile Phone

Address

City

State/Province

Zip/Postal

Height (Feet)

Height (Inches)

Weight (lbs)

Date of Birth

Gender

Male

Female

Please choose the race and/or ethnicity that describes yourself. Choose all that apply:

Do you have knee pain?

Yes

No

Have you been diagnosed with osteoarthritis of the knee by a doctor?

Yes

No

Have you had any injections in your knee?

Yes

No

Do you have any of the following health conditions?

Cancer in the last 5 years

Poorly controlled diabetes (i.e., not on any treatment)

Allergies to medications such as opioids, NSAIDS, etc

Cardiac Disease (e.g., myocardial infarction, seizures, stroke, etc.)

Kidney Disease

Liver Disease

Respiratory disease (such as COPD, history of P.E., etc.)

History of HIV, Hepatitis B, or Hepatitis C

None

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