Medical History Form printable pdf download

Orthopaedic Surgery

NEW PATIENT INFORMATION

Patient Identification

Who referred you to our office? Name/Address/Phone/ Speciality:

________________________________________________________________________________

Is there anyone else you would like to receive information about your orthopedic care?

_________________________________________________________________________________

_______________________________________________________________________________

Why are you being seen today?  Right Side  Left Side  Both Sides

Please describe your current orthopedic problem/injury (how it started symptoms, etc):

________________________________________________________________________________

Date of onset (or approximate duration of the problem if onset was gradual): __________________

Circle the number that best represents your average pain level over the last week:

(No pain) 0

10 (worst pain imaginable)

Circle the number that best represents your overall disability/dysfunction level:

(No dysfunction) 0

10 (wheelchair/bedbound)

Check all that apply

Pain Quality:  Sharp

 Aching

 Stabbing

 Throbbing

 Burning/tingling

Associated Symptoms:  Swelling

 Locking/catching  Instability/giving way  Stiffness

Timing of Pain:  Morning

 Night

 Worse as day goes on  Activity-related

 With walking/standing  With running/exercise  Gets better with activity, or as day goes on

 Start-up pain (worse with first few steps after sitting/resting)

Have you ever had a similar pain/problem in the past?

 Yes  No

What makes it better? ____________________________________________________________

What makes it worse? ____________________________________________________________

Prior treatment:  Rest

 Cane/Crutches/Walker

 Orthotics/Shoe inserts/Pads

 Night splint  Brace (#wks, type?)___________________________  Boot (# wks): ________

 Cast (# wks): ______

 Physical Therapy (#wks): ______

 Other: ____________________

Medication (name/dose/duration): ____________________________________________________

Injections (How many? % Improvement, duration?) _______________________________________

Prior Surgery for this problem or body part (who/where/when/what): __________________________

________________________________________________________________________________

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Medical History Form

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