Orthopaedic Specialists
Date:_________________________
Name: ___________________________________
Who referred you:
Age: ______ Date of Birth: _______________
_________________________________________________________________
Primary Care Physician: _________________________________________________________________
CURRENT CONDITION:
Current Orthopaedic Complaint: __________________________________________________________
Circle One:
Elbow
Knee
Shoulder
Circle One: LEFT
Wrist
RIGHT
Ankle
Hip
Foot
BILATERAL
Are you right or left handed? _________________________________________
Date of onset of injury/problem: __________________________________________________________
Is your injury/problem related to: auto accident _____ work related accident _____
MEDICAL CONDITIONS
Do you currently have or have you ever had any of the following conditions?
Condition
HEART DISEASE/CHEST PAIN
Condition
Yes  No 
HEART VALVE PROBLEMS/MURMUR Yes  No 
PNEUMONIA/BRONCHITIS
Yes  No 
EMPHYSEMA/COPD
Yes  No 
HIGH BLOOD PRESSURE
Yes  No 
SINUS PROBLEMS
Yes  No 
HEARTBURN/REFLUX/ULCER
Yes  No 
DIABETES
Yes  No 
LIVER DISEASE/HEPATITIS
Yes  No 
THYROID DISEASE
Yes  No 
ANEMIA
Yes  No 
RHEUMATOID ARTHRITIS
Yes  No 
BLEEDING DISORDER
Yes  No 
GOUT
Yes  No 
BLOOD CLOTS/DVT
Yes  No 
OSTEOARTHRITIS
Yes  No 
KIDNEY DISEASE
Yes  No 
SLEEP APNEA
Yes  No 
KIDNEY STONES
Yes  No 
FRACTURE/BROKEN BONE
Yes  No 
ASTHMA
Yes  No 
CANCER
Yes  No 
SHORTNESS OF BREATH
Yes  No 
NEUROLOGICAL DISORDER
Yes  No 
If not listed above, please list any other MEDICAL CONDITIONS: ____________________________
_____________________________________________________________________________________
Date of your last flu vaccine: ___________
Date of your last pneumonia vaccine: __________
SURGICAL HISTORY:
Procedure:
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Date:
________________________
________________________
________________________
________________________
________________________
FAMILY HISTORY:
Mother: Living or Deceased
Father: Living or Deceased
Family Member
Cancer:
Yes
I am adopted: yes or no
Family Member
No ________________ High Cholesterol: Yes No ________________ ____
Cancer Type: __________
Hypertension:
Yes No ____________________
Diabetes I or II: Yes
No ________________ Thyroid Disease: Yes No ____________________
Heart Disease:
No ________________
Yes
SOCIAL HISTORY:
Single_____ Married _____ Partnered _____ Separated _____ Divorced _____ Widowed _____
Occupation: __________________________________________ Are you working now? Yes  No 
Current Smoker: How many packs/day? ______________ Number of years: __________
Former Smoker: _____
Never a Smoker: ______
Do you drink alcohol? Yes 
No 
History of substance abuse? Yes 
How much and how often? _____________________________
No 
If yes, please describe: __________________________
Is there any possibility that you are pregnant? Yes  No  (If yes, please inform staff prior to x-rays.)
Please list all CURRENT MEDICATIONS/DOSES:
Medications
Dosage
Times per day
________________________________
_______________
____________
________________________________
_______________
____________
________________________________
_______________
____________
________________________________
_______________
____________
________________________________
_______________
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________________________________
_______________
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________________________________
_______________
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________________________________
_______________
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________________________________
_______________
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ALLERGIES TO
MEDICATIONS:_____________________________________________________________________
Patient Signature: __________________________________________ Date: ___________________