Comprehensive Orthopedic Medical History Form

Patient Information

• Full Name: _________________ Date of Birth: _________
• Address: __________________ Phone: _______________
• Emergency Contact: __________ Relationship: _________

Current Complaint

• Primary reason for visit: _________________________
• Location of pain/problem: ________________________
• Pain scale (0-10): _____ Duration: ________________
• Symptoms began: □ Gradually □ Suddenly
• Related to: □ Injury □ Work □ Auto accident □ Unknown

Pain Characteristics

• Type: □ Sharp □ Dull □ Burning □ Throbbing □ Stabbing
• Frequency: □ Constant □ Intermittent □ Occasional
• What makes it worse? ____________________________
• What makes it better? ____________________________

Past Medical History

Previous Orthopedic Conditions

• Previous fractures: □ Yes □ No Details: ____________________________________
• Previous surgeries: □ Yes □ No Details: ____________________________________

General Medical History

□ Arthritis □ Osteoporosis □ Diabetes □ Heart Disease □ High Blood Pressure □ Blood Clots □ Other: _____________________________________

Current Medications

Family History

□ Arthritis □ Osteoporosis □ Other bone/joint conditions: ____________________

Social History

• Occupation: _________________________________
• Physical activity level: □ Sedentary □ Moderate □ Active
• Tobacco use: □ Never □ Current □ Former
• Alcohol use: □ Never □ Occasional □ Regular

Certification

I certify that the above information is accurate to the best of my knowledge.

Signature: _________________ Date: _______________