Patient forms

In order to save time, you can download our new patient forms. This is the standard form from the American College of Rheumatology. You will need Adobe to view these files

Pre-Operative Checklist

Post-Operative Instructions

New Patient

If you are a new patient, create your medical record here, then book an appointment for your services using the appointment booking form below.

Create your medical record

Step 1 of 8

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General Information

Name

First Last

Date of Birthday

MM slash DD slash YYYY

Gender

ID#

Phone

Referring doctor

Insurance

How did you hear about us?

Social Media

Friend

Relative

Existing Patient

Other

Address

In case of an emergency, who should we contact?

Name

First Last

Relationship

Phone

Injury Details

What problem are you here to have looked at today?

Please describe what happened or you got injured

How long has it been going on?

What makes it better?

What makes it worse?

On a scale of 0 to 10; 0 being no pain and 10 being severe pain. How severe is the pain?

Where, No pain is 1 and 10 is severe pain.

What treatments have you tried so far?

Medical History

Are you allergic to or had a bad reaction to any of the following? If yes, please tick the appropriate box/boxes

Aspirin

Penicillin

Codeine

Local Anesthetic

General Anesthetic

Latex

Sulfur

Other

Other:

Do you or your family have a history of medical problems?

Yes

If yes, please list all related prescribed medications in the space provided.

Anemia / Blood Disorder

Yes

Describe:

Arthritis (Osteo/Rheumatoid)

Yes

Describe:

Asthma

Yes

Describe:

Cancer

Yes

Describe:

Chest Pains

Yes

Describe:

Diabetes

Yes

Describe:

Heart Disease

Yes

Describe:

Hemophilia (Bleeding Problems)

Yes

Describe:

High Blood Pressure

Yes

Describe:

Surgical History

Have you had any surgical procedures?

Yes

If yes; please state what surgery and the approximate dates

Approximate date of Surgery

MM slash DD slash YYYY

Have you ever been hospitalized?

Yes

If yes; please state when you were hospitalized and the approximate dates

Approximate date of hospitalization

MM slash DD slash YYYY

Medical History Continued

If you are experiencing any of the following due to the area of injury, please tick yes where applicable

Abnormal heart rhythm

Yes

Anxiety

Yes

Chest pain

Yes

Depression

Yes

Diabetes

Yes

Gout

Yes

Heart attack

Yes

Heartburn

Yes

Joint pain

Yes

Joint swelling

Yes

Leg cramps

Yes

Muscle pain

Yes

Numbness

Yes

Poor healing

Yes

Rheumatoid arthritis

Yes

Shortness of breath

Yes

Sleep apnea

Yes

Tingling

Yes

Unexpected weight gain

Yes

Unexpected weight loss

Yes

PROTECTION COMPLIANCE DECLARATION

Please read the following carefully and tick if you agree or leave blank if you disagree, in the box provided.

I understand that the information I’ve provided on this form may influence my treatment and that the information, is to the best of my knowledge, true and accurate.

I hereby permit Optimum Orthopaedics to hold this form on file and hold my clinic records.

I understand that the information will be kept in confidence and not shared with any third party unless prior written consent had been provided.

I consent to the examination, which includes the use of touch and some non-invasive instruments. After this, appropriate treatment(s) will be proposed to me (the medical patient), which I have the right to opt out of, ask questions about or consent to.

I agree to photography and videography of my treatment (does not include facial, any distinctive marks, such as tattoos, birth marks, piercings, etc.) in relation to my treatment and to aid any referral information to other health professionals by agreement to maximize treatment.

This field is for validation purposes and should be left unchanged.

Book an Appointment

If you are returning or doing a follow up, Book an Appointment here:

Note: Any further procedure done in the office during your appointment will have an extra cost

Location

Staff

Service

Service Extras

Date & Time

Recurring info

Information

Cart

Confirmation

Have any questions?

246-538-7285

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