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Synvisc patients outcome survey |
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The Sports medicine Institute of Indiana |
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| Last Name | |
| First Name | |
| Middle Initials | |
| Age | |
| Sex | |
| Knee | |
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Pain during normal daily activities like walking, running or riding a bike (visual analog scale - 0 is no pain and 10 is the worst pain) |
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Pain in rest sitting or laying down (visual analog scale - 0 is no pain and 10 is the worst pain) |
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Pain at night wile you are in the bed sleeping (visual analog scale - 0 is no pain and 10 is the worst pain) |
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Restriction of activity (visual analog scale - 10 is can not have any activity and 0 is for normal activity level for your stile of life) |
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Using the VAS below please click on the number that represents your satisfaction with the treatment, where 0 means completely unsatisfied with the treatment patient and 10 stays for the best result you have had. |
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| Catching or grinding sensation in the knee | |
| Swelling of the knee | |
| Using any kind of helping devise to walk | |
| Using drugs for the pain | |
| Any additional procedures (please describe) | |
Thank you!