ORTHOPAEDIC SURGERY
NEW PATIENT FORM
Name (printed):___________________________________ Date of Birth: ______________ Age:________
Family Doctor:_____________________________ Referring Doctor:_______________________________
Chief complaint (reason for visit – be specific):
______________________________________________
For how long have you had your symptoms?
______days ______weeks ______months ______years
Was there an accident/fall associated with it?
_____________________________________________
Are you right or left-handed? (circle one)
RIGHT-HANDED
What kind of symptoms are you experiencing?
NUMBNESS
TINGLING
WEAKNESS
CLICKING
LOCKING
CATCHING
GIVING WAY
FALLING
2
3
LEFT-HANDED
On a scale of 1-10, rate your pain
1
4
5
Describe (circle) the quality of the pain
SHARP
Does the pain radiate (shoot down or up)?
_____________________________________________
When is it worse?
MORNING
NIGHT
Does it wake you up from a sound sleep
YES
NO
Does putting weight on it make it
BETTER
WORSE
Does anything else make it worse?
_____________________________________________
What type of treatments have you tried?
ICE/HEAT
DULL
6
7
8
9
LIKE A TOOTHACHE
WITH ACTIVITY
10 (worst)
BURNING
AT REST
SAME
CRUTCHES
PHYSICAL THERAPY
NONE
MEDICATION
INJECTIONS (date of last injection)
SURGERY
Have you had any imaging?
X-Ray CT
MRI
Bone Scan
Other
Please draw out your symptoms.
Use “X” for pain and “O” for a numbness
(use arrows to show shooting pain)
Please sign on the top line.
This information is accurate to the best of my knowledge:
Patient
Date
I have reviewed this information with the patient:
Physician
FRONT
BACK
Date
ORTHOPAEDIC SURGERY
NEW PATIENT FORM
MEDICAL HISTORY
Have you ever had the following problems? (circle all that apply)
Cancer (tumor) – What kind?
Hay Fever /// Asthma
Emphysema /// COPD /// Tuberculosis /// Pneumonia
Unusual bleeding /// Anemia (low blood)
DVT (blood clot in the leg) /// PE (blood clot in the lungs)
Diabetes (sugar)
Thyroid Disease
Epilepsy (fits/seizures/convulsions) /// Stroke
Arthritis (osteoarthritis) /// Rheumatism /// Lupus /// Gout
High Blood Pressure
Heart attack /// Heart failure /// Rhythm Trouble
High Cholesterol
Hepatitis /// Cirrhosis /// Other Liver Problems
Gallstones /// Other Gallbladder Problems
Stomach Problems /// Reflux (heartburn) /// Ulcers
Kidney Trouble /// Bladder Trouble
Anxiety /// Depression /// Other Emotional Problem
Reaction To Anesthesia – What kind?
Please list all surgeries you have had:
Surgery
Date
Where
Surgeon
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
Please list all the medicines you are currently taking (including over the counter medicines)
Drug
Dose
Frequency
Drug
Dose
Frequency
___________________________________________ _____________________________________________
___________________________________________ _____________________________________________
___________________________________________ _____________________________________________
___________________________________________ _____________________________________________
___________________________________________ _____________________________________________
___________________________________________ _____________________________________________
MEDICATION ALLERGIES:
Please answer the following social questions:
Do you currently smoke or chew?
Y N __________ packs/cans per day and for___________ years
Did you ever smoke or chew?
Y N When did you quit?
Do you drink alcohol?
Y N How often?
___________________________________
_________________________________________
What do you do for a living?
Do you exercise? How often?
Marital status? (circle one)
Single
Married
Separated / Divorced
Does anyone in your family have a history of (list relatives in space provided)
Cancer
Y
N ______________________________________________
Heart Disease
Y
N ______________________________________________
High Cholesterol
Y
N ______________________________________________
Diabetes
Y
N ______________________________________________
Lung Disease
Y
N ______________________________________________
High Blood Pressure
Y
N ______________________________________________
Bleeding or Blood Clotting Disorder
Y
N ______________________________________________
Reaction to Anesthesia
Y
N ______________________________________________
Have you experienced any of the following within the past 6 months? (circle all that apply)
Unintentional Weight Loss
Frequent Fevers /// Sweats /// Chills
Serious Problems with Eyes
Serious Problems with Ears
Difficulty Swallowing
Frequent Cough /// Wheezing
Shortness of Breath at Rest /// Shortness of Breath With Activity
Racing Heart (palpitations)
Chest Pain at Rest /// Chest Pain With Activity
Frequent Constipation /// Frequent Diarrhea
Frequent Rectal Bleeding /// Tar-like Stool
Frequent Nausea /// Vomiting
Frequent Pain or Problems Urinating
Persistently Swollen Glands
Skin Problems /// Skin Sores
Redness of Joints /// Swelling in Joints
Unusual or Persistent Back Pain
Excessive Stress from Home or Work
Persistent Swelling the Legs or Ankles
Frequent Headaches
The information provided in this form is accurate to the best of my knowledge.
Patient’s Signature
Date
I have personally reviewed the information in this form with the patient.
__________________________________________________________________________________________
Physician’s Signature
Date
Thank you for filling out this questionnaire. Your doctor will see you shortly.