Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: Name:
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1 Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: Name: Date of birth: Website: Age: Occupation: What is your primary concern? Pain location: Have you had surgery for this injury? No Yes Type of surgery/dates: History of falls in last year: No Yes Hospitalization in last 3 months? No Yes Medical History: Fracture or Suspected Fracture Rheumatoid Arthritis Alzheimer s High Blood Pressure Traumatic Brain Injury Cardiovascular Disease History of Cancer Allergies: Cauda Equina Syndrome Huntington s Unexplained Weight Loss CVA / Stroke Immunosuppression Pacemaker Current Infection Lupus Pregnant Diabetes Mellitus Type 1 Diabetes Mellitus Type 2 Seizures Muscle Dystrophy Osteoarthritis Blood Clots HIV/AIDS Hepatitis B/C Other: Diagnostics: X-Ray MRI CT Scan Diagnostic Ultrasound Results of Imaging: Medications: See attached Where is your problem? Indicate on the body chart. Nature of pain/symptoms (check all that apply): sharp aching constant dull periodic throbbing occasional other Are your symptoms: Improving Getting Worse Staying the Same What activities make your pain worse? What activities make your pain better? Have you ever had treatment before for these symptoms? No Yes If yes, list treatments: Overall activity level: Sedentary Light Heavy Copyright Evercore, LLC. All Right Reserved.
2 Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0 1 KOOS KNEE SURVEY Today s date: / / Date of birth: / / Name: INSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how well you are able to perform your usual activities. Answer every question by ticking the appropriate box, only one box for each question. If you are unsure about how to answer a question, please give the best answer you can. Symptoms These questions should be answered thinking of your knee symptoms during the last week. S1. Do you have swelling in your knee? S2. Do you feel grinding, hear clicking or any other type of noise when your knee moves? S3. Does your knee catch or hang up when moving? S4. Can you straighten your knee fully? S5. Can you bend your knee fully? Stiffness The following questions concern the amount of joint stiffness you have experienced during the last week in your knee. Stiffness is a sensation of restriction or slowness in the ease with which you move your knee joint. S6. How severe is your knee joint stiffness after first wakening in the morning? S7. How severe is your knee stiffness after sitting, lying or resting later in the day?
3 Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0 2 Pain P1. How often do you experience knee pain? Monthly Weekly Daily What amount of knee pain have you experienced the last week during the following activities? P2. Twisting/pivoting on your knee P3. Straightening knee fully P4. Bending knee fully P5. Walking on flat surface P6. Going up or down stairs P7. At night while in bed P8. Sitting or lying P9. Standing upright Function, daily living The following questions concern your physical function. By this we mean your ability to move around and to look after yourself. For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A1. Descending stairs A2. Ascending stairs
4 Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0 3 For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A3. Rising from sitting A4. Standing A5. Bending to floor/pick up an object A6. Walking on flat surface A7. Getting in/out of car A8. Going shopping A9. Putting on socks/stockings A10. Rising from bed A11. Taking off socks/stockings A12. Lying in bed (turning over, maintaining knee position) A13. Getting in/out of bath A14. Sitting A15. Getting on/off toilet
5 Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0 4 For each of the following activities please indicate the degree of difficulty you have experienced in the last week due to your knee. A16. Heavy domestic duties (moving heavy boxes, scrubbing floors, etc) A17. Light domestic duties (cooking, dusting, etc) Function, sports and recreational activities The following questions concern your physical function when being active on a higher level. The questions should be answered thinking of what degree of difficulty you have experienced during the last week due to your knee. SP1. Squatting SP2. Running SP3. Jumping SP4. Twisting/pivoting on your injured knee SP5. Kneeling Quality of Life Q1. How often are you aware of your knee problem? Monthly Weekly Daily Constantly Q2. Have you modified your life style to avoid potentially damaging activities to your knee? Not at all ly ly ly Totally Q3. How much are you troubled with lack of confidence in your knee? Not at all ly ly ly Q4. In general, how much difficulty do you have with your knee? ly Thank you very much for completing all the questions in this questionnaire.
6 Informed Consent for Physical Therapy Physical therapy involves the use of many different types of physical evaluation and treatment. At Evercore, we use a variety of procedures and modalities to improve your function. As with all forms of medical treatment, there are benefits and risks involved with physical therapy. Since the physical response to a specific treatment can vary widely from person to person, it is not always possible to accurately predict your response to a certain therapy modality or procedure. We are not able to guarantee precisely what your reaction to a particular treatment might be, nor can we guarantee that our treatment will help the condition you are seeking treatment for. There is also a risk that your treatment may cause pain or injury, or may aggravate previously existing conditions. You have the right to ask your physical therapist what type of treatment he or she is planning based on your history, diagnosis, symptoms and testing results. You may also discuss with your therapist what the potential risks and benefits of a specific treatment might be. You have the right to decline any portion of your treatment at any time before or during your treatment session. Therapeutic exercises are an integral part of most physical therapy treatment plans. Exercise has inherent physical risks associated with it. If you have any questions regarding the type of exercise you are performing and any specific risks associated with your exercises, your therapist will be glad to answer them. I acknowledge that my treatment program has been explained by Evercore, and all of my questions have been answered to my satisfaction. I understand the risks associated with a program of Physical Therapy as outlined to me, and I wish to proceed. Client Name Client Signature Date Copyright Evercore, LLC. All Rights Reserved.
7 Cancellation Policy We understand there are times when situations arise that make it necessary for you to cancel your appointment. It is your responsibility to call us as soon as you know you will not make your appointment. This allows us to fill your spot with another client who wants that time slot. A cancellation fee of $35 will be charged if you cancel within 24-hours. Note: Please be on time for your session. If you are late, the session will still finish on time. These policies help the us provide quality care to our valued clients. If you have any questions or need clarification of any of the above policies, please do not hesitate to call us. Contact Info: Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: marc@evercorelife.com CLIENT S SIGNATURE DATE Copyright Evercore, LLC. All Right Reserved.
8 Expectations with Physical Therapy What can physical therapy do for me? Physical therapy will help you reduce pain, recover from your injuries, reduce your risk of injury and increase your strength. Physical therapy helps you get back to the things you love and feel more active We may use hands-on techniques, movements and exercises to correct the underlying factors contributing to your injury. You will learn how to manage your injuries and pain without surgery, injections or pain medications. How long is each session? Each session consists of 30-minutes of one-on-one training with Dr. Marc. You may be here for 45-minutes total to complete your mobility and movement therapy exercises What should I wear? Wear athletic clothes We have a shower you can use if you need to shower before you go back to work. What should I bring? Bring a water bottle if you want. We have purified water to refill your water bottle. Fill out the forms in this folder and bring the forms with you to your next session. Bring your smartphone if you want me to record you doing exercises on your phone. You can reference these videos for your home exercise program. Home exercise program You will receive exercises to perform at home. I will send you a PDF handout with pictures of your exercise program. We may use your smartphone to record you doing your exercises. Movement analysis We may do a video movement analysis using a smartphone. We will be analyzing your movements during functional activities like squats, lunges, reaching overhead, or other activities that are difficult for you. Copyright Evercore, LLC. All Right Reserved.
9 Will I feel sore after our sessions? There is a difference between muscle soreness and pain. It is normal to feel muscle soreness. It is normal to have setbacks while recovering from an injury. We will assess your progress each session and make changes as needed to ensure you are improving. How long will it take for me to get better? Your ability to reduce or eliminate pain will be determined by several factors such as: length of time you have been dealing with the injury, severity of the injury, normal healing time of the injury, and your consistency with the home exercise program. Within 4-6 weeks, you should have significantly less pain and feel more active. How can I get better faster? Follow your exercise program and show up for each physical therapy session Allow time for your body to heal and do not rush the recovery process What is our contact information? Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: marc@evercorelife.com Visit our website for helpful videos, articles and resources to recover from injuries and get stronger. Follow us on social media for daily exercise videos: Instagram: Evercorelife Facebook: Evercore YouTube Channel: Evercorelife If you have any additional questions or comments feel free to contact us. To your health, Dr. Marc Robinson, PT, DPT, Cert. MDT Physical Therapist/Co-founder of Evercore Copyright Evercore, LLC. All Right Reserved.
Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: Name:
Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA 92123 Phone: 1-800-760-5469 Name: Email: marc@evercorelife.com Date of birth: Website: www.evercorelife.com Age: Occupation: What is your primary
Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA Phone: Name:
Address: 8898 Clairemont Mesa Blvd Suite J, San Diego, CA 92123 Phone: 1-800-760-5469 Name: Email: marc@evercorelife.com Date of birth: Website: www.evercorelife.com Age: Occupation: What is your primary
KOOS KNEE SURVEY. These questions should be answered thinking of your knee symptoms during the last week.
Knee injury and Osteoarthritis Outcome Score (KOOS), English version LK1.0 1 KOOS KNEE SURVEY Today s Date: / / Date of Birth: / / Name: Please rate your pain level with activity: 0 1 2 3 4 5 6 7 8 9 10
KOOS KNEE SURVEY. Today s date: / /
KOOS KNEE SURVEY Name: Today s date: / / Date of Birth: / / INSTRUCTIONS: This survey asks for your view about your knee. This information will help us keep track of how you feel about your knee and how
S6. How severe is your foot/ankle joint stiffness after first wakening in the morning? None (+0) Mild (+1) Moderate (+2) Severe (+3) Extreme (+4) ( )
Foot and Ankle Outcome Score (FAOS) Survey Patient Name: Date: Patient MRN: Affected Foot/Ankle: R L (Circle One) Instructions: This survey asks for your opinion about your foot/ankle and helps us understand
O 5-10 O O O >20 O <10 O O 0 O 1 O 2 O 3 O 4 O <5 O 6-9 O O 15
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