Orthopedic Intake Form: What to Include for Musculoskeletal Practices

Orthopedics covers sports injuries, degenerative joint disease, and accident trauma. Whatever the case, three things matter most: pain location, functional impact, and mechanism of injury. Document those well and most of the clinical intake is done before the visit.

Demographics and Contact Information

Full name, date of birth, address, phone, email, emergency contact, and occupation: a warehouse worker and a software developer with the same shoulder injury have different return-to-work plans.

Reason for Visit and Referral

• Primary complaint
• Referring physician (name, practice, phone)
• Referral or prescription upload
• Is this related to a workers' compensation claim?
• Is this related to an auto accident?
• Is this related to a personal injury claim?

These three questions need conditional logic. A "yes" to any should expand into:

• Date of injury/accident
• Claim number
• Insurance adjuster or attorney name and contact
• Employer (for workers' comp)
• Description of incident

Capturing this upfront avoids authorization delays.

Injury and Condition Details

Get precise:

• What body part or region is affected?
• When did the problem start? (specific date or approximate timeframe)
• Was there a specific injury or event, or did it develop gradually?
• If injury: describe what happened
• Is the condition getting better, worse, or staying the same?
• Have you had this problem before?
• Previous treatment for this condition (medications, PT, injections, bracing, surgery)

Pain Assessment

• Location: a checklist of body regions with left/right, plus a short description
• Pain scale: 0-10 at rest, with activity, and at its worst
• Pain character: sharp, dull, aching, throbbing, burning, stabbing, radiating
• Timing: constant vs. intermittent, worse at what time of day
• Aggravating activities: specific movements or positions
• Relieving factors: rest, ice, medication, position changes
• Night pain: does pain wake them from sleep? (indicates severity)

Radiation matters: back pain below the knee, or neck pain with hand numbness, changes the workup.

Functional Limitations

What can't the patient do right now?

• Walking distance and tolerance
• Stair climbing
• Lifting capacity
• Overhead activities
• Sitting tolerance
• Standing tolerance
• Sports and recreational activities affected
• Work restrictions or modifications currently in place
• Use of assistive devices (brace, sling, cane, walker, crutches)

Add a functional score: "From 0 to 100%, where 100% is normal, what is your current function?" It's quick and tracks progress.

Surgical History

• Previous orthopedic surgeries (procedure, body part, date, surgeon)
• Joint replacements (type, date, which joint)
• Spinal surgeries
• Arthroscopic procedures
• Hardware currently in place (plates, screws, rods)
• Complications from previous surgeries

Imaging History

• X-rays (body part, date, facility, findings)
• MRI (body part, date, facility, findings)
• CT scan
• Bone scan
• Ultrasound
• Can the patient upload or bring imaging? (file upload field)

Imaging in hand before the visit prevents duplicate orders.

Medical History and Medications

Full medication list, allergies, and medical conditions. Flag conditions that affect orthopedic decision-making:

• Diabetes (wound healing, infection risk)
• Osteoporosis (fracture risk, hardware decisions)
• Blood clotting disorders or anticoagulant use
• Cardiac conditions (surgical risk assessment)
• Autoimmune conditions (inflammatory arthritis, lupus)
• Smoking status (affects bone healing significantly)

Treatment Goals

Return to sport, pain-free daily life, back to work, avoiding surgery? Capture it in the patient's own words to align expectations early.

Consent and Insurance

Consent for examination and treatment, HIPAA privacy notice, e-signature. Standard insurance fields: carrier, member ID, group number, subscriber information.

Building Your Orthopedic Form

In Formisoft, the AI builder drafts the framework, conditional logic hides the accident and workers' comp sections unless relevant, pages keep it manageable, and file upload takes imaging and referrals. Sent before the appointment, it means the evaluation starts with the exam, not a clipboard. See how patient readiness works.