Sports Medicine Orthopedic Surgeon – Houston, TX Dr. David Lintner, M.D.

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)

Home
About Dr. Lintner
- In the News
- Our Staff
Sports Injuries
- Knee Injuries
- Shoulder Injuries
Surgery Information
Rehab Protocols
Articles
Make an Appointment

Subscribe to RSS feed

Knee Injury Questionnaire for New Patients

Download the Questionnaire for New Patients with Knee Injuries in PDF format.

Please complete this form BEFORE your appointment.

Name*
PrefixFirstLastSuffix
Age*
Height*
Weight*
Email Address*
Best Daytime Phone*
Who is your primary care physician?
When did you last see him/her?
Have you ever had any of the following (in the past)?
- Asthma
- Balance Problems
- Bladder or Urinary Infections
- Blood in Stools
- Blood Clots
- Cancer
- Chest Pain
- Chronic Bronchitis
- Cramping in Leg While Walking
- Colitis
- Deep Venous Thrombosis
- Diabetes
- Dizziness
- Emphysema
- Fainting
- Frequent Bloody Noses or Bleeding Gums
- Gallstones
- Heart Attack
- Heart Murmur
- Heart Surgery
- High Blood Pressure
- High Cholesterol
- Joint Replacement
- Kidney Stones
- Osteoporosis
- Poor Circulation
- Recurrent Infections
- Shortness of Breath
- Slowly Healing Wounds
- Stomach Ulcer
- NORMAL. I've had none of the above.
Type of Cancer?
Review of Systems...
Do you currently have any of the following?
- Reaction of NSAID/anti-inflammatory medications (Advil, ibuprofen, Naproxen, Indocin, Celebrex, etc.)
- Fever or chills.
- Recent weight gain or recent weight loss.
- Changes in vision, sensitivity to light, blurred vision, double vision.
- Change in hearing, bloody noses, sore throat, cough.
- Shortness of breath, chest pain, wheezing, coughing of blood.
- Palpitations, light headedness, dizziness.
- Loss of appetite, weight loss, pain with swallowing, nausea, vomiting, abdominal pain or bloating, blood in your stools, diarrhea, constipation.
- Difficulty urinating, pain with urination, blood in your urine.
- Rashes, insect bites, new skin lesions.
- NORMAL. I've had none of the above.
What medications do you take?
Are you allergic to any medications?
- Yes
- No
To which medications are you allergic?
Do you smoke?
- Yes
- No
How many packs per day?
How much alcohol do you drink?
What surgeries have you had in the past?
Knee History...
To which knee do the following apply?
- Right
- Left
When did your knee problem begin?
How did it start?
- Sports Injury
- Work Injury
- Overuse (Running, cycling, swimming, etc.)
- Work Overuse
- Gradually
- Spontaneously (For no apparent reason.)
Have you had this problem before?
- Yes
- No
What part of your knee hurts?
- Front
- Behind Kneecap
- Inner (Medial) Side
- Outer (Lateral) Side
- Behind the Knee
What makes the pain worse?
- Activity
- Prolonged standing.
- Prolonged sitting with knee bent (i.e. in a theatre).
- Running, but not walking/standing.
- Going up or down stairs.
- Squatting
- Kneeling
- Twisting or pivoting with this leg.
Does the pain wake you up from sleep?
- Yes
- No
Is the pain worse when you first start walking and then better when you are “warmed up”?
- Yes
- No
Do you have any of the following?
- Painful popping.
- Sensation of catching. (Something getting caught/pinched between the bones.)
- Locking (Suddenly unable to straighten the knee because something obstructs it.)
- Grinding
- Swelling
- None of the above.
Does the knee ever...
- Give way? (The bones slip out of place.)
- Buckle?
- Slip out of joint?
- Get stuck?
Describe your job's physical demands...
- Manual labor including kneeling, squatting, climbing, carrying, etc. (Construction, laborer.)
- Moderate: Walking, stairs, on feet all or most of day.
- Office environment with frequent walking and time on your feet.
- Desk Job
- Student
- Athlete
- Other
Are you currently working at your usual job?
- Yes
- No, light duty.
- No, off work due to injury.
- No, off work for other reasons.
What were your typical most strenuous recreational activities before your knee problem began?
- High intensity sports (football, basketball, racquetball, etc.)
- Moderate intensity sports (recreational skiing, running, cycling, etc.)
- Low intensity sports (walking, golf, etc.)
- Activities of daily living.
What are your most strenuous activities since your knee problem began?
- High Intensity
- Moderate intensity sports (recreational skiing, running, cycling, etc.)
- Low intensity sports (walking, golf, etc.)
- Manual Labor
- Desk Job
- Activities of daily living.
To what type of activities do you intend to return after your knee problem resolves?
- High Intensity
- Moderate intensity sports (recreational skiing, running, cycling, etc.)
- Low intensity sports (walking, golf, etc.)
- Manual Labor
- Desk Job
- Activities of daily living.
Do you run for exercise/recreation? If so, how many miles per week?
- Less than 10 miles per week.
- 10-20 miles per week.
- More than 20 miles per week.
- Don't run.
What prior injuries have you had to this knee?
- NONE
- Cartilage or Meniscus Tear
- Ligament Tear (ACL, MCL, PCL, LCL)
- Bone Chips
- Sprain/Strain
- Patellar Dislocation
- Other
Have you had an MRI?
- Yes
- No
What did the MRI show?
What surgeries have you had on this knee?
- Arthroscopy
- Cartilage / Meniscectomy (removal of cartilage)
- Cartilage / Meniscus Repair
- Debridement / cleaning out
- ACL reconstruction
- Other
Year of your Arthroscopy?
Please enter a value between 1950 and 2020.
Year of your Cartilage/Meniscectomy?
Year of your Cartilage/Meniscus Repair?
Year of your Debridement?
Year of your ACL Reconstruction?
What other surgery did you have, and in what year?
What are your goals for this visit?
- Gain information regarding your problem.
- Make sure it is okay to remain active.
- Correct the problem as long as it does not need surgery.
- Correct the problem even if it needs surgery.
eSignature
- I certify that I am the patient named above, and that all the responses contained in this form are accurate to the best of my knowledge.
- I certify that I am the parent or legal guardian of the patient named above, and that all the responses contained in this form are accurate to the best of my knowledge.
Name of Parent or Legal Guardian
PrefixFirstLastSuffix
Name
This field is for validation purposes and should be left unchanged.

Like this? Share it:
Email
LinkedIn
Facebook
Twitter

Sports injury? Injury related to other activity?

Tell us about your knee injury!
Tell us about your shoulder injury!

Dr. David Lintner

Dr. David Lintner specializes in arthroscopic surgery of the knee and shoulder and is active in teaching orthopedic surgeons the latest techniques. He also specializes in injuries to throwers’ shoulders and elbows, having written more than thirty scientific articles about ACL injuries, thrower’s injuries, and other sports medicine issues.

Read more about Dr. David Lintner

Pages in this Site

Orthopedic Sports Medicine Specialist
Dr. David Lintner
Our Staff
Sports Injuries
Surgery Information
Rehab Protocols
Appointments
Articles
Contact

Most Recent Articles

Dr. Lintner interviewed about faking of injuries in the NFL.
US News and World Report names Dr. Lintner to “The Best Doctors in America”
Radio Interview
How Texas is Striving to Make Football Safer
A Little Preparation Can Make for Safer Skiing

Orthopedic Links

American Association of Orthopedic Surgeons
DS2 Rehab Systems (The DS2 Platform)
Journal of the American Academy of Orthopaedic Surgeons
The American Orthopaedic Society For Sports Medicine

Rehabilitation

DS2 Rehab Systems (The DS2 Platform)

Sports Links

DS2 Rehab Systems (The DS2 Platform)
TSU Tigers

Timmons Office: (713) 441-3560 (map)
Baytown Office: (832) 556-0880 (map)

©2003-2010 Dr. Lintner, MD. All Rights Reserved.

Dr. David Lintner is an orthopedic sports medicine specialist practicing in Houston, TX, as well as team doctor to many of the professional teams in the Houston area.

Other Resources

Send to Email Address Your Name Your Email Address

Cancel

Post was not sent - check your email addresses!

Email check failed, please try again

Sorry, your blog cannot share posts by email.