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KNEE MRI QUESTIONNAIRE

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PATIENTS NAME:

Date:

DIAGNOSIS (What complaints or symptoms caused you to seek medical help?)

PLEASE CHECK EACH BOX THAT APPLIES TO YOU (AND ANSWER QUESTIONS:)

How long have you had these symptoms?

Did they develop suddenly or gradually?

 Suddenly Gradually

Does your knee lock?

 Yes No
 

If yes, how and when?

Do you click when walking?

 Yes No

Do you feel something move in your knee when walking?

 Yes No

Does your knee give?

 Yes No
 

If yes, how?

Have you had surgery on this knee?

 Yes No
 

Anthroscopic Surgery?

 Yes No
 

Open Surgery?

 Yes No
 

If yes, when?

 Where?

Did you have Menisectomy?

 Yes No

Did you have Ligament Repair?

 Yes No
 

If yes, which ligament?

 Cruciates Other
     

PRIOR STUDIES AND INTERVENTION:
 
 

Prior MRI (when?)

(Where?)
 

X-Ray (when?)

(Where?)
 
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