Orthopedics — New Patient Consultation Template

Consultation Information

Referring physician: [Name, specialty]
Reason for referral: [Chief complaint]
Date of consultation: [Date]
Interpreter needed: Yes / No — Language: [X]

Chief Complaint

Primary concern: [Body part, symptom]
Side: Right / Left / Bilateral
Duration: [Onset date/timeline]
Current status: Improving / Stable / Worsening

History of Present Illness

[Detailed narrative of current musculoskeletal complaint]
Mechanism of injury: [If traumatic]

• Date of injury: [Date]
• Activity at time: [Sport, work, fall, MVA, etc.]
• Specific mechanism: [Description]
• Immediate symptoms: [What patient felt/noticed]

Onset: Acute / Gradual / Insidious
Progression: Stable / Progressive / Fluctuating

Pain Assessment

Location: [Specific anatomic location]
Character: Aching / Sharp / Burning / Throbbing / Stabbing
Severity: [X]/10 at worst, [X]/10 at best, [X]/10 currently
Radiation: None / [Pattern]
Timing: Constant / Intermittent — Worse: AM / PM / Night
Aggravating factors: [Activity, position, movement]
Relieving factors: [Rest, ice, heat, position, medication]
Night pain: Yes / No — Awakens from sleep: Yes / No

Functional Status

Work status: Full duty / Modified duty / Disabled / Retired

• Occupation: [Type, physical demands]
• Work restrictions: [Current limitations]

Sports/recreation: [Activities, current ability to participate]
ADLs affected:

• Walking: [Distance, assistive device]
• Stairs: [Ability, handrail needed]
• Sitting tolerance: [Duration]
• Standing tolerance: [Duration]
• Sleep: Unaffected / Disrupted by pain

Prior Treatment

Conservative measures tried:

• Rest/activity modification: Yes / No — Duration: [X]
• Physical therapy: Yes / No — Duration: [X weeks], Sessions: [X]
• Medications: [NSAIDs, acetaminophen, etc.]
• Ice/heat: Yes / No
• Bracing/splinting: Yes / No — Type: [X]
• Injections: Yes / No — Type: [Cortisone, HA, PRP], Date: [X], Response: [X]
• Chiropractic: Yes / No

Response to treatment: None / Minimal / Moderate / Significant
Prior surgeries (affected area): None / [Procedure, date, outcome]
Prior imaging: [X-ray, MRI, CT dates and locations]

Past Medical History

Relevant conditions:

• Diabetes: Yes / No — [Control status]
• Rheumatoid/inflammatory arthritis: Yes / No
• Osteoporosis: Yes / No
• Bleeding disorders: Yes / No
• Peripheral vascular disease: Yes / No
• Neuropathy: Yes / No

Other: [Medical conditions]

Past Surgical History

[List surgeries with dates]

Medications

[Current medications, especially anticoagulants, steroids, immunosuppressants]

Allergies

[Drug allergies and reactions]

Social History

Tobacco: Current / Former / Never — Pack-years: [X]
Alcohol: [Frequency, amount]
Living situation: [Home type, stairs, support available]
Hand dominance: Right / Left

Physical Examination

General: [Appearance, gait observation, assistive devices]
Gait: Normal / Antalgic / [Specific abnormality]

• Stance phase: [Observation]
• Swing phase: [Observation]

[Affected Joint/Region] Examination

Inspection:

• Skin: Intact / [Ecchymosis, swelling, erythema, scars]
• Alignment: Normal / [Deformity: varus, valgus, flexion contracture]
• Muscle bulk: Symmetric / Atrophy [location]
• Swelling: None / Mild / Moderate / Severe

Palpation:

• Point tenderness: [Specific locations]
• Effusion: None / Mild / Moderate / Large
• Warmth: None / Present
• Crepitus: None / Present

Range of motion:

• Active: [Degrees for each motion]
• Passive: [Degrees for each motion]
• Limited by: Pain / Mechanical block / Weakness

Strength (0-5 scale):

• [Relevant muscle groups]: [X]/5
• [Relevant muscle groups]: [X]/5

Stability testing:

• [Relevant ligament tests]: Stable / Unstable [grade]

Special tests:

• [Test name]: Positive / Negative
• [Test name]: Positive / Negative

Neurovascular:

• Sensation: Intact / Diminished [distribution]
• Pulses: 2+ / [Diminished, absent]
• Capillary refill: <2 sec / Delayed

Contralateral comparison: [Symmetric / Asymmetric findings]

Imaging Review

X-rays: [Date, views, findings]

• Alignment: [Normal, malalignment]
• Joint space: [Normal, narrowing]
• Bone quality: [Normal, osteopenic]
• Osteophytes: None / [Location]
• Fracture: None / [Description]

MRI: [Date, findings if available]

• [Relevant structures and pathology]

CT: [If applicable]
Other: [Bone scan, EMG, etc.]

Assessment

1) [Primary diagnosis] — [Laterality, severity]
[Staging/classification if applicable]
2) [Secondary diagnoses]

Treatment Options Discussed

Conservative Management

• Activity modification: [Specific recommendations]
• Physical therapy: [Focus areas]
• Medications: [NSAID, analgesic recommendations]
• Bracing/orthotics: [Type if indicated]
• Injections: [Type, location if indicated]
• Expected timeline: [Weeks to improvement]

Surgical Management (if indicated)

• Procedure: [Name]
• Indication: [Why surgery recommended]
• Alternatives: [Non-operative options]
• Risks: [Procedure-specific risks]
• Benefits: [Expected outcomes]
• Timeline: [Urgency, scheduling]

Plan

1) [Immediate management steps]
2) Diagnostic workup:

• Imaging: [Additional studies needed]
• Labs: [If indicated]

3) Treatment initiated:

• [Medications, therapy, bracing]

4) Surgical planning: [If applicable]

• Pre-operative workup: [Clearance, labs]
• Scheduling: [Timeline]

5) Restrictions:

• Work: [Specific limitations]
• Activity: [Weight-bearing, lifting, sports]

6) Follow-up:

• Return: [Timeframe]
• Sooner if: [Warning signs]

Patient Education

Diagnosis explanation, treatment rationale, expected recovery timeline, activity precautions, warning signs (increased pain, numbness, weakness, signs of infection), medication instructions, therapy expectations.

Communication

Report sent to referring physician: Yes
Copy to: [PCP, other providers]