Orthopedic Intake Form: What to Include for Musculoskeletal Practices

Orthopedic practices see everything from sports injuries to degenerative joint disease to post-accident trauma. Your intake form needs to flex across these very different presentations while capturing the specific details that drive diagnosis and treatment planning.

The common thread: pain location, functional impact, and mechanism of injury. Get these three things documented well, and you've done most of the clinical intake work before the patient walks in.

Demographics and Contact Information

Full name, date of birth, address, phone, email, emergency contact. Include occupation, as it's clinically relevant. A warehouse worker with a shoulder injury has different treatment considerations and return-to-work expectations than a software developer with the same diagnosis.

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

Workers' comp and accident cases have specific documentation requirements. Capturing this upfront avoids back-and-forth with the patient and delays in authorization.

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

Orthopedic pain assessment should be structured and detailed:

• Location: body diagram where the patient can mark specific areas
• 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)

Radiating pain patterns matter. Low back pain that stays in the back is different from low back pain that radiates below the knee. Neck pain that causes hand numbness changes the workup entirely.

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)

Include a functional score: "On a scale of 0-100%, where 100% is your normal activity level, what is your current function level?" Quick, measurable, and useful for tracking progress.

Surgical History

Orthopedic surgical history is particularly relevant:

• 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)

Having imaging results before the appointment can prevent duplicate orders and speed up the treatment plan.

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

What does the patient want to achieve? Return to sport, pain-free daily activities, return to work, avoid surgery? Document this in the patient's own words. Aligning expectations early prevents frustration later.

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

Formisoft makes orthopedic intake forms manageable despite their length. The AI builder generates the framework, conditional logic hides accident/workers' comp sections unless relevant, multi-page layout breaks the form into logical sections, and file upload handles imaging and referral documents.

Send it before the appointment. The patient arrives with complete documentation, and your evaluation starts with the physical exam instead of a clipboard.

Build your orthopedic intake form with Formisoft, try it free.