VENKATESH KNEE ASSESSMENT FORM

NAME

AGE

KNEE: LEFT/RIGHT

HISTORY

SYMPTOM START DATE

INJURY DESCRIPTION

PAIN-MEDIAL/LATERAL/ANTERIOR/POSTERIOR

WALKING DISTANCE               NIGHT PAIN

PAIN ON STAIR CLIMBING OR WALKING DOWN INCLINES

SWELLING: Y/N

GIVING WAY Y/N                     WHEN AND HOW MANY TIMES

LOCKING Y/N

PATELLA DISLOCATIONS- DISLOCATIONS/SUBLUXATIONS- HOW OFTEN

TREATMENT: MEDICATION

                      PHYSIOTHERAPY

PREVIOUS SURGERY:

PAST MEDICAL HISTORY/ALLERGIES

OCCUPATION/ LEISURE ACTIVITIES/TEGNER SCORE

EXAMINATION

STANDING ALIGNMENT                   GAIT

QUADRICEPS

FIXED VARUS/VALGUS AND RANGE OF MOTION SYMMETRICAL EXTENSION Y/N/PAIN

PAIN ON DEEP FLEXION Y/N

EFFUSION GRADE

JOINTLINE TENDERNESS: MEDIAL/LATERAL

LACHMAN                   POSTERIOR SAG

LCL/MCL

PIVOT SHIFT

DIAL TEST- (30) (90)               MCMURRAY

PATELLA: TRACKING               LATERAL TIGHTNESS

MEDIOLATERAL DISPLACEMENT

TENDERNESS

GENERALISED LAXITY

SPINE     HIPS     FEET     PEDAL PULSE

XRAY               LAXITY MEASUREMENTS

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