1. What is your current level of discomfort?
0
1
2
3
4
5
6
7
8
9
10
Very Low
Very High
2. Where do you experience pain or discomfort?
Back / Neck
Knees
Ankles
Hips
Shoulders
Elbows
Wrists / Hands
3. How would you describe your pain/discomfort?
(Choose all that apply.)
My knee is swollen
My knee grinds and pops
It feels weak when I walk
My knee buckles when I stand or walk
Sharp pain
Dull pain
I limp when I walk
None of the above
4. When did the pain/discomfort begin?
Less than a month ago
1-3 months ago
3-6 months ago
6-12 months ago
More than a year ago
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