New Patient Information Form

Department of  ORTHOPAEDIC SURGERY

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NEW PATIENT INFORMATION FORM                 Printer Required

INSTRUCTIONS:   Please fill out the information requested below and print
out the form. Bring the printed information with you to your initial appointment at the clinic. Other options: Return to: New Patient Information
Go to: Clinic Locations / Homepage.

Appointment Date:

Appointment Time:

Orthopaedic Physician:

Patient's Name:

Street Address:

City:

State:

Zip:

Phone:

Date of Birth:  

Height:           

Weight:          

Referring Problem Area and Side of Body Affected: (example: right knee)


Onset of Symptoms:


Specific Injury or Other:


Where Injury Occurred: (example: work, home, accident)


Previous Surgeries Related to this Problem:


Current Medications and Drug Allergies:


Related Problems:
Fever
Weight Loss
Eyes
Head and Neck Problems
Heart
Lungs
Gastrointestinal Problems
GU
Previous Orthopaedic Injuries
Skin and Breast Problems
Endocrine
Immunologic

Significant Past Medical History:


Significant Past Family History:


Social History: (single/married, alcohol use, drug use, tobacco use, current occupation)


Referring Physician Name:

Referring Clinic:  

Referring Clinic Street Address:

Referring Clinic City:

State:

Zip:

Referring Clinic Phone: (Include Area Code)

Primary Care Physician: (If different from your referring physician)


Primary Clinic:

Primary Clinic Street Address:

Primary Clinic City:

State:

Zip:

Primary Clinic Phone: (Include area code)

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When you have completed this form, please PRINT IT and BRING IT WITH YOU to your scheduled appointment at the Orthopaedic Surgery Clinic. This will help to expedite your appointment.

NOTICE: Please DO NOT send any confidential information to us by Email. Documents that you send to us by email may not be secure. If you choose to send any confidential information to us via e-mail, you accept the risk that a third party may intercept this information. © 2003-2005 by the Regents of the University of Minnesota.

Return to: New Patient Information
Go to: Clinic Locations / Homepage