Stanford Integrative Osteoarthritis Management Decision Making Aid

Name:                                                                                                                 Age:

Date: 

Osteoarthritis Severity Score From WOMAC:

Current Medications:

Over the Counter:
Name:                         Dosage:                         Frequency:                            Length of Use:
Name:                         Dosage:                         Frequency:                            Length of Use:
Name:                         Dosage:                         Frequency:                            Length of Use:

Prescription:

Name:                        Dosage:                         Frequency:                             Length of Use:
Name:                        Dosage:                         Frequency:                             Length of Use:
Name:                        Dosage:                         Frequency:                             Length of Use:

Current Herbal Supplements/Vitamins/Minerals:

Name:                         Dosage:                      Frequency:              Length of Use:

Other Conventional Therapies:

Chiropractic

Phyisical Therapy

Other

Surgeries:__________________________________________________________________________________

Other Non Conventional Therapies:_______________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

 
        Yoga

        Massage

         Tai Chi

         Acupuncture

         Water Aerobics 
                                  
         Resistance Training

Other:_____________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________

Concerns:__________________________________________________________________________________ __________________________________________________________________________________________ __________________________________________________________________________________________