Joint Works Assessment

Take a Minute to Complete This Personal Assessment

Many treatments can help relieve hip or knee pain, but is it enough? Should you consider other options, such as physical therapy or surgery? Please take a minute to complete this self-assessment. It will help you take the next step in improving the quality of your life.

Please select the appropriate number

First name:		Address:
Middle Initial:		City:
Last name:		State:
Phone Number:		Zip:
Email:		Date of Birth:
Primary Care Physician's Name:

My hip and knee pain is:

	1 (moderate, but getting worse)
	2 (severe, trouble sleeping, wakes me)

My hip and knee pain:

	1 (does not restrict my activities)
	2 (keeps me from enjoying life)

Non-prescription painkillers:

	1 (make the pain go away)
	2 (don't help at all)

I can walk:

	1 (normally)
	2 (with a cane)

I can bend from the waist or knee:

	1 (normally)
	2 (rarely or never)

I have numbness down my leg:

	1 (no)
	2 (yes)

My joint buckles, grinds or "pops":

	1 (1-2 times/week)
	2 (3-5 times/week)

I have joint stiffness and limited motion:

	1 (1-2 times/month)
	2 (all the time)

I am on prescription painkillers, which I:

	1 (need to use 1-2 times/month)
	2 (must use every day)

I have been diagnosed with osteoarthritis, rheumatoid arthritis, bursitis or other bone condition:

	1 (no)
	2 (yes)

I have been experiencing pain:

	1 (for up to 6 months)
	2 (for more than 6 months)