Adult Pre-Evaluation Form
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1Orthopaedic Surgery Specialists, Ltd. – Adult Pre-Evaluation Form
Orthopaedic Surgery Specialists, Ltd. – Adult Pre-Evaluation Form
Orthopaedic Surgery Specialists, Ltd. – Adult Pre-Evaluation Form
Orthopaedic Surgery Specialists, Ltd. – Adult Pre-Evaluation Form
Orthopaedic Surgery Specialists, Ltd. – Adult Pre-Evaluation Form
Patient Name
Patient Name
Patient Name
Patient Name
Patient Name
Age
Age
Age
Age
Age
Date of Birth
Date of Birth
Date of Birth
Date of Birth
Date of Birth
/
/
/
/
/
/
/
/
/
/
Occupation
Occupation
Occupation
Occupation
Occupation
Are you right or left handed?
Are you right or left handed?
Are you right or left handed?
Are you right or left handed?
Are you right or left handed?
What is the reason for your visit today?
What is the reason for your visit today?
What is the reason for your visit today?
What is the reason for your visit today?
What is the reason for your visit today?
When was the onset of your injury/problem?
When was the onset of your injury/problem?
When was the onset of your injury/problem?
When was the onset of your injury/problem?
When was the onset of your injury/problem?
How did this occur? (If applicable)
How did this occur? (If applicable)
How did this occur? (If applicable)
How did this occur? (If applicable)
How did this occur? (If applicable)
Have you had previous treatment for this injury/problem? (i.e. ER, Primary Care Physician)
Have you had previous treatment for this injury/problem? (i.e. ER, Primary Care Physician)
Have you had previous treatment for this injury/problem? (i.e. ER, Primary Care Physician)
Have you had previous treatment for this injury/problem? (i.e. ER, Primary Care Physician)
Have you had previous treatment for this injury/problem? (i.e. ER, Primary Care Physician)
Are you currently taking any medications? If so, what are they and what are they for?
Are you currently taking any medications? If so, what are they and what are they for?
Are you currently taking any medications? If so, what are they and what are they for?
Are you currently taking any medications? If so, what are they and what are they for?
Are you currently taking any medications? If so, what are they and what are they for?
Do you have any allergies to medications? If so, what are they and what is the reaction?
Do you have any allergies to medications? If so, what are they and what is the reaction?
Do you have any allergies to medications? If so, what are they and what is the reaction?
Do you have any allergies to medications? If so, what are they and what is the reaction?
Do you have any allergies to medications? If so, what are they and what is the reaction?
Do you have any other medical problems? If so, what are they?
Do you have any other medical problems? If so, what are they?
Do you have any other medical problems? If so, what are they?
Do you have any other medical problems? If so, what are they?
Do you have any other medical problems? If so, what are they?
Have you had any hospitalizations or injuries? If so, please list.
Have you had any hospitalizations or injuries? If so, please list.
Have you had any hospitalizations or injuries? If so, please list.
Have you had any hospitalizations or injuries? If so, please list.
Have you had any hospitalizations or injuries? If so, please list.
Are you active in any sports/recreation activities? If so, please list.
Are you active in any sports/recreation activities? If so, please list.
Are you active in any sports/recreation activities? If so, please list.
Are you active in any sports/recreation activities? If so, please list.
Are you active in any sports/recreation activities? If so, please list.
Do you smoke?
Do you smoke?
Do you smoke?
Do you smoke?
Do you smoke?
Yes No
Yes No
Yes No
Yes No
Yes No
Do you drink alcohol?
Do you drink alcohol?
Do you drink alcohol?
Do you drink alcohol?
Do you drink alcohol?
Yes No
Yes No
Yes No
Yes No
Yes No
Do you use recreational drugs?
Do you use recreational drugs?
Do you use recreational drugs?
Do you use recreational drugs?
Do you use recreational drugs?
Yes No
Yes No
Yes No
Yes No
Yes No
Do you or anyone in your family have/had the following?
Do you or anyone in your family have/had the following?
Do you or anyone in your family have/had the following?
Do you or anyone in your family have/had the following?
Do you or anyone in your family have/had the following?
Abdominal Pain
Abdominal Pain
Abdominal Pain
Abdominal Pain
Abdominal Pain
Cancer
Cancer
Cancer
Cancer
Cancer
Heart Disease
Heart Disease
Heart Disease
Heart Disease
Heart Disease
Blood Clots/Stroke
Blood Clots/Stroke
Blood Clots/Stroke
Blood Clots/Stroke
Blood Clots/Stroke
Chest Pain
Chest Pain
Chest Pain
Chest Pain
Chest Pain
Nerve Problems
Nerve Problems
Nerve Problems
Nerve Problems
Nerve Problems
Blood Infections (Hepatitis, HIV)
Blood Infections (Hepatitis, HIV)
Blood Infections (Hepatitis, HIV)
Blood Infections (Hepatitis, HIV)
Blood Infections (Hepatitis, HIV)
Difficulty Breathing
Difficulty Breathing
Difficulty Breathing
Difficulty Breathing
Difficulty Breathing
Vision Problems
Vision Problems
Vision Problems
Vision Problems
Vision Problems
Bone Problems
Bone Problems
Bone Problems
Bone Problems
Bone Problems
Difficulty with Anesthesia
Difficulty with Anesthesia
Difficulty with Anesthesia
Difficulty with Anesthesia
Difficulty with Anesthesia
Bowel or Bladder Problems
Bowel or Bladder Problems
Bowel or Bladder Problems
Bowel or Bladder Problems
Bowel or Bladder Problems
Headaches
Headaches
Headaches
Headaches
Headaches
Is there any other significant family medical history the doctor should be aware of?
Is there any other significant family medical history the doctor should be aware of?
Is there any other significant family medical history the doctor should be aware of?
Is there any other significant family medical history the doctor should be aware of?
Is there any other significant family medical history the doctor should be aware of?
*If you have any other pertinent information that you would like to share with the doctor, please use the backside of
*If you have any other pertinent information that you would like to share with the doctor, please use the backside of
*If you have any other pertinent information that you would like to share with the doctor, please use the backside of
*If you have any other pertinent information that you would like to share with the doctor, please use the backside of
*If you have any other pertinent information that you would like to share with the doctor, please use the backside of
this form.
this form.
this form.
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