Musculoskeletal intake that localizes the problem before the exam — pain, mechanism, and function.
Healthcare template · 13 fields (6 required) · ~3 min for respondents to complete · Free plan · No credit card · Fully customizable
About this form
Orthopedic evaluation starts with a history that this form structures completely: where the pain is, how severe, what it feels like, when and how it started, what treatments have been tried, and — the question that drives surgical versus conservative decisions — how it limits function. Collected before the visit, it lets the exam start at the problem instead of at the beginning.
The injury-mechanism and symptom-onset fields matter diagnostically: an acute twisting injury and a gradual onset point to different differentials before any imaging is ordered. The previous-treatments inventory prevents re-prescribing the six weeks of physical therapy the patient already completed elsewhere.
Best practices
Functional impact is the field to weight in triage — "cannot climb stairs" says more about urgency than any pain score.
Cross-reference pain level with functional impact; the mismatches (low pain, high limitation, or the reverse) are diagnostically interesting in both directions.
The previous-treatments checklist is your conservative-care documentation — insurers increasingly require it before authorizing imaging or surgery.
Capture the referring physician reliably; orthopedics runs on referral relationships, and the report-back is what keeps them.
Every field, explained
Patient Name (Name, required)
Date of Birth (Date, required)
Chief Complaint (Long text, required)
Location of Pain/Problem (Multiple choice) — A body-region checklist so multi-site complaints are captured completely, not just the worst one.
Pain Level (1-10 scale) (Single choice, required)
Pain Characteristics (Multiple choice)
When did symptoms begin? (Single choice, required)
Mechanism of Injury (Multiple choice) — Trauma, overuse, or insidious onset — the answer that shapes the differential before imaging.
Previous Treatments (Multiple choice) — Documents the conservative care already tried — clinically useful and increasingly required for authorization.
Functional Impact (Single choice, required) — The triage field: functional limitation predicts urgency better than reported pain.
Current Medications (Long text)
Medical History (Multiple choice)
Referring Physician (Short text)
Frequently asked questions
What should an orthopedic evaluation form include?
Pain location, severity, and character; symptom onset and injury mechanism; treatments already tried; functional impact; current medications; and relevant medical history. This template captures each as a structured field so the clinical picture is complete before the exam.
Why ask about previous treatments on an intake form?
Two reasons: clinically, it prevents repeating what has already failed; administratively, documented conservative care is what many insurers require before authorizing MRI or surgical consultation. The checklist format makes that documentation automatic.
Is this orthopedic form HIPAA compliant?
The template is HIPAA-ready: on a HIPAA-enabled plan, submissions are encrypted, access-controlled, audit-logged, and covered by a Business Associate Agreement.
Related healthcare templates
Patient Intake Form — Comprehensive patient information and medical history form