Thank You | Icarus Medical

Next Steps

Please tell us a little more about your knee condition.

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First Name*

Last Name*

Email Address*

Phone*

Zip Code*

I have a knee injury or condition.*

Yes

No

Some activities make my knee pain worse.*

Yes

No

I would like an Icarus rep to contact me with more information.*

Yes

No

I have health insurance.*

Yes

No

I am a veteran who goes to the VA for medical care.*

Yes

No

Which knee(s)/leg(s) is affected?

Left

Right

Injury Type(s)

Osteoarthritis

Patellofemoral OA

Meniscus Injury

Anterior Cruciate Ligament (ACL)

Other Knee Ligament

Rheumatoid Arthritis

Bone Fracture

Muscular Dystrophy

Parkinson's Disease

Huntington's Disease

Cerebral Palsy

Stroke

Spinal Cord Injury

Charcot-Marie-Tooth

General Mobility Assistance

Other Injury

Other Injury

Treatment History

Non-Steroidal Anti-Inflammatory Drugs (NSAIDs)

Acetaminophen

Opioids

Physiotherapist

Chiropractor

Orthotics

Massage

Soft Knee Brace

Rigid Knee Brace

Physical Therapy or Exercise

Cane

Walker

Wheelchair

Cortisone Injections

Hyaluronic Acid Injections

Plasma Injections

Arthroscopic Surgery

Knee Replacement Surgery

None

Other

Other

Activities With Pain

Going Up Stairs

Going Down Stairs

Standing From Seated

Staying Seated

Crouching Or Squatting

Hiking Or Walking On Uneven Ground

Walking On A Flat Surface

None

Other

Other

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