Trinitas Diagnostic Imaging
415 Morris Avenue, Elizabeth, NJ 07208
908-351-7600 (Phone) | 908-351-4406 (Fax)
www.TrinitasDiagnosticImaging.com

If you're coming to our center for this test, print this page, fill out the form and bring it in with you on the day of your appointment.

 

FIRST NAME
LAST NAME
AGE

WEIGHT   DATE  
WHAT WAS YOUR CHIEF COMPLAINT WHEN YOU VISITED YOUR DOCTOR?





WHICH KNEE IS AFFECTED?
LEFT   RIGHT
WHICH SIDE OF YOUR KNEE HURTS?
INSIDE
OUTSIDE
FRONT
BACK
NO PAIN
WHAT DO YOU THINK CAUSED THE PROBLEM?





DOES YOUR KNEE LOCK?
YES   NO
HAVE YOU EVER HAD KNEE SURGERY?
YES   NO
DO YOU HAVE ANY OTHER MEDICAL CONDITIONS OR PROBLEMS?





DESCRIBE YOUR GENERAL HEALTH?