Orthopedic Practice New Patient Registration Form

Patient Information

• Full Name: ____________________________
• Date of Birth: //____
• Gender: □ Male □ Female □ Other
• SSN: --___
• Address: ____________________________
• Phone: (__) -
• Email: ____________________________
• Emergency Contact: _________________ Phone: (__) -

Insurance Information

• Primary Insurance: ____________________
• Policy Number: ______________________
• Group Number: ______________________
• Policy Holder Name: _________________

Medical History

Current Symptoms

• Primary Complaint: ____________________
• Location of Pain/Discomfort: ___________
• Duration: ___________________________
• Pain Level (0-10): ___

Previous Orthopedic History

• Previous Surgeries: □ Yes □ No
  • If yes, please list: _________________
• Previous Injuries: □ Yes □ No
  • If yes, please describe: _____________

General Medical History

• Current Medications: _________________
• Allergies: __________________________
• Medical Conditions:
  • □ Arthritis
  • □ Osteoporosis
  • □ Diabetes
  • □ Heart Disease
  • □ High Blood Pressure
  • □ Other: _________________________

Consent

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

Signature: _____________ Date: //____