Pre-Operative Evaluation
Welcome back to Epic Orthopedics! Please take a moment to answer these questions before you are taken to your exam room. When you are done please let the receptionist know and they will instruct you on the next steps.
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Name (First Last): *
Appointment Date: *
MM
/
DD
/
YYYY
Surgery Date: *
MM
/
DD
/
YYYY
Which side are you having surgery on? *
How long have you had pain/problems? *
How bad is your pain today? *
Best
Worst
Are you currently, or have you been taking prescription pain medications? (Narcotics or Opioids) *
Have you tried weight loss as a solution for your pain? *
What therapy have you tried? (select all that apply) *
Required
Have you had injections in your painful joint? (select all that apply) *
Required
Do you have issues with any of the following? (select all that apply) *
Required
Does/did any of your family members have issues with any of the following? (select all that apply) *
Required
Have you had issues with: (select all that apply) *
Required
Do you take any of the following medications? (select all that apply) *
Required
Do you now smoke or have you smoked in the past? *
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