Orthopedics Intake Form
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The Orthopedics Intake Form is built for orthopedic surgery practices, sports medicine clinics, and musculoskeletal specialty offices. It captures detailed information about bone, joint, and muscle complaints: injury mechanism, onset and progression, pain characteristics, functional impact, imaging history, and previous orthopedic treatments.
The joint function assessment section uses validated screening questions to evaluate range of motion limitations, instability, locking, clicking, and weight-bearing capacity. Patients can indicate affected joints on a visual body diagram. Activity limitations are documented across categories including work, sports, daily living, and sleep.
Surgical history is captured with specific attention to orthopedic procedures, hardware placement, and post-surgical complications. The imaging section documents previous X-rays, MRI, CT scans, and bone density studies with dates and facilities. This template also captures workers' compensation and auto accident information when applicable, streamlining the administrative process for injury-related visits.
What's included
- Musculoskeletal complaint and injury mechanism
- Pain assessment and joint function screening
- Imaging and surgical history
- Activity limitation documentation
- Workers' comp and auto accident details
- Insurance information collection with carrier and policy details
- Consent agreement with e-signature
Who uses this template
- Orthopedic surgery practices
- Sports medicine clinics
- Joint replacement centers
- Workers' compensation injury clinics
All form fields
14 fields across 3 pages. Customize any field after signing up.
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