Current Knee Condition

RightLeftBoth

Less than 4040 – 5555+

How long have you been experiencing knee pain or discomfort?
Less than 3 months3–12 monthsOver 1 year

How would you describe your knee pain? (Select all that apply)
ConstantIntermittentSharp/stabbingDull/achingStiffnessWeaknessLocking or giving way

On a scale of 1 to 10 (1 being no pain, 10 being severe pain), how would you rate your knee pain today?
12345678910

Have you experienced any of the following symptoms? (Select all that apply)
Swelling or inflammationClicking or popping soundsDifficulty straightening or bending the kneeNumbness or tingling around the kneeLimping or difficulty walkingNone

Have any other these treatments provided significant or lasting relief?
YesNo

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20%

Treatment History

What treatments or approaches have you tried in the past? (Select all that apply)

PhysiotherapyChiropractic careMassage therapyAcupunctureSurgeryPainkillers or anti-inflammatory medicationsCortisone injectionsDietary changes or supplementsExercise programsNone

Have any of these treatments provided significant or lasting relief?

YesNo

Have you undergone diagnostic imaging? Please check off applicable.

X-rayMRICT ScanUltrasoundNone

Describe if "Other"

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40%

Lifestyle and Daily Activities

Do you find it challenging to perform any of the following activities? (Select all that apply)
WalkingSitting for extended periodsClimbing stairsKneeling or prayingExercising or playing sportsNone

How would you describe your current lifestyle?
SedentaryModerately activeVery active

Are you willing to make lifestyles changes to achieve better knee heath? (Diet, Excersise, Lifestyle changes Etc).
YesNo

Do you currently experience any of the following symptoms?
ConstipationDiarrheaGasBloatingHeartburnRedness, itchinessHeadaches/MigrainesDifficultly breathingChronic fatigueRunny noseBrain fogLack of focus/concentrationNone

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60%

Goals and Mindset

What is your knee pain preventing you from doing?

Have you ever worked with a coach or participated in an online program for health or fitness?
YesNo

Do you feel comfortable using technology (e.g., video calls, online classes, apps) as part of your treatment plan?
YesNo

Are you ready to invest time, effort, and financial resources into a comprehensive approach to reversing your knee pain?
Yes, I’m ready to invest fully.I’m unsure but willing to learn more.No, I’m looking for a quick fix.

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80%

Additional Information

Are there any specific allergies, sensitivities, or medical conditions we should know about?

What do you feel has been the biggest barrier to resolving your knee pain?

Is there anything else you’d like to share about your knee condition or overall health?

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100%