Orthopedic Surgical Patient Questionnaire
Please complete this questionnaire to help the orthopedic care team prepare for your surgery and pre-operative planning.
Patient Information
Full Name
*
First Name
Middle Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Emergency Contact Name and Phone Number
*
First Name
Middle Name
Last Name
Orthopedic Condition and Surgical History
Affected body area or joint
*
Please Select
Shoulder
Elbow
Wrist/Hand
Hip
Knee
Ankle/Foot
Spine/Neck
Other
Primary reason for surgery
*
Please Select
Pain
Instability
Limited range of motion
Fracture or injury repair
Arthritis or joint degeneration
Tendon or ligament repair
Hardware removal
Other
Current diagnosis or injury
*
How long has this condition been present?
*
Prior treatments tried
Physical therapy
Medications or injections
Bracing or immobilization
Activity modification
Assistive device use
Chiropractic or other therapy
None
Other
Prior orthopedic surgeries
Imaging or other tests related to this condition
X-ray
MRI
CT scan
Ultrasound
Bone scan
EMG or nerve testing
Laboratory tests
None
Other
Medical Background and Risk Screening
Current medications
Medication allergies
Latex allergy
*
Yes
No
Unsure
Past medical conditions
History of anesthesia complications
*
Yes
No
Unsure
Smoking status
*
Never
Former
Current
Prefer not to say
Alcohol use
None
Occasional
Moderate
Heavy
Prefer not to say
Mobility limitations
Walking
Stairs
Standing
Lifting
Reaching
None
Other
Assistive devices used
None
Cane
Walker
Crutches
Wheelchair
Brace
Orthotics
Other
Current infection, fever, or open wounds
*
Infection
Fever
Open wounds
None
Surgery Planning and Preparation
Preferred surgery date
-
Month
-
Day
Year
Date
Surgeon or clinic name
Side of body to be operated on
*
Left
Right
Both
Other
Availability for pre-op appointments
Transportation or escort support on surgery day
*
Yes, I will have support
No, I need help arranging support
Not sure yet
Special accessibility or communication needs
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