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EFTA00311062 | EFTA00311065 Orthopaedic Clinical Intake Form MRN: Name: Tre Pc R e7s-rErNi Date of Birth: REVIEW OF SYSTEMS: Are you currently having or have you had problems with your: alyes, check box to right ofsymptoms that apply) Constitutional No/ Yes Fatigue° Headache° Fever° Weight Loss° Other: Elm No / Yes Glasses° Blurred vision0 Other. Ears,Nose,Throat No / Yes Congestion° Hearing Loss° Jaw discomfort° Other: Lungs, Breathing No / Yes Cough° Wheezing° Shortness of breath° Other: Heart No / Yes Heart munnursO Irregular heartbeat° Other: Gastrointestinal No/ Yes Nausea0 Vomiting° Stomach aches° Constipation° Diarrhea° Other: Bladder No / Yes Incontinence° Urinary tract infections° Difficulty urinating° Other: Endocrine No / Yes Diabetes° Thyroid problems° Delays in growth° Other. Musculoskeletal No / Yes Joint pain0 Leg painO History of broken bones° Other: Bleeding No / Yes Anemia° Prolonged Bleeding after cut/injwyD Other: Neurological No/ Yes Dizziness° Numbnesshingling0 Headaches° Frequent fallsO Other: Integumentary No / Yes Rashest] Skin Disorders° Connective tissue disorders° Other. Psychiatric No / Yes Change in mood or behavior° Change in sleep patterns° Other: Immunologic/ Anemic No / Yes Asthma° Hay fever° Chronic rashest] Communicable Diseases° Other: Signature (Person Completing Form) Date Completed Physician Signature Date FOR OFFICE USE ONLY: Initials below indicate Allergies, Medications, and Problems have been data entered as discrete elements into the CROWN System. Additionally, the indicated elements of Section #1 have been data entered into the CROWN System as discrete data: Family History Past Surgical History Past Medical History Social History Initials Scan Folder: Onho Intake Form Page 3 of4 Revised 2/2/12 EFTA00311065
April 27, 2026 at 2:53 AM