First Last Age
DOB Height Weight
Hand Dominance:
Today's Date (mm/dd/yyyy)
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Comprehensive Patient Questionnaire
Referring Doctor Information
Name
Specialty
City/State Phone
Primary Doctor Information
Name
Specialty
City/State Phone
History of your current orthopedic problem
The problem primarily involves:
(check all that apply)		 ( R L) ( R L)
( R L) ( R L) ( R L) ( R L)
When did this problem start? Approximate date of onset:
What caused the problem?
Did this injury occur at work?
Will a workers' compensation claim be filed?
Describe your pain
How Severe Is This Problem?
Is The Pain Getting Better Or Worse Over Time?
What makes the problem better?
What makes the problem worse?
Have you recently visited an ER for this problem?
Date: Facility:
What treatment(s) did you receive in the ER?
Previous Non-surgical treatments?
(Check all that apply)
List previous treatment/surgeries for this problem
 Doctor Specialty City
Medications taken for this problem
 Name of medication(s) Dose For how long
X-rays / tests for this problem Results Date Where
Past Medical History
 Check all items that apply and describe below if necessary. Otherwise check none.
Describe:
When diagnosed Controlled with:
Loss of feeling:
Type(s)
Past Surgical History: Not indicated previously
Operation Date Surgeon Operation Date Surgeon
Medications: (include vitamins and herbs)
Medication/strength Dose Reason Medication/strength Dose Reason
Allergies to Medications
Medication Reaction(s) Medication Reaction(s)
Family History (Check all that apply)
Social History (Check all that apply)
Occupation:
Work Status:
Marital Status:
Habitation:
Tobacco use:
Packs per day: For years (total) years ago
Alcohol use:
Drug use:
Types of drugs:
Review of Symptoms
 Check all items that apply and describe below if necessary. Otherwise check none.
Loss of feeling in:
PATIENT OR PARENT SIGNATURE
 X_______________________________________________________
DATE
 __________________
Because of this orthopedic problem, do you plan to file
***For Office Use Only***

I have read and confirmed the above information with the patient


SIGNATURE:__________________________________________DATE:_________________

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