Orthopedic Consultation Form

Orthopedic Consultation Form — Form Fields

This healthcare template includes 8 fields. Orthopedic consultation intake form for patients seeking evaluation of bone, joint, or musculoskeletal concerns. Captures injury history, pain details, and functional limitations. Free to customize and use on ZenBuild.

• Patient Name (text, required)
• Area of Concern (dropdown selection, required) — options: Shoulder, Elbow / Wrist / Hand, Spine / Back, Hip, Knee, Ankle / Foot, Multiple areas
• Reason for Visit (dropdown selection, required) — options: Acute injury, Chronic pain, Sports injury, Post-fracture follow-up, Surgical consultation, Second opinion
• Current Pain Level (1 = mild, 5 = severe) (rating, required)
• When did the problem start? (text, required)
• Previous Treatments Tried (select all that apply) (checkboxes, optional) — options: Physical therapy, Cortisone injection, Over-the-counter pain medication, Bracing / splinting, Chiropractic care, Surgery on this area, None
• Functional Limitations (select all that apply) (checkboxes, optional) — options: Difficulty walking, Difficulty climbing stairs, Unable to work, Difficulty sleeping due to pain, Cannot participate in sports/exercise
• Upload Imaging Results (X-ray, MRI, etc.) (file upload, optional)