Patient Information: Orthopaedic Surgery

Patient Information
Patient Questionnaire: Orthopedic surgery
Preferred Language*
Patient Name (as displayed on your health insurance card)*

First NameLast Name
Patient Gender*
Today System

YearMonthDay
Patient Birth Date*

MonthDayYear
Patient Age*
Height and Weight in (select units)
Patient Height (m)*
Patient Weight (kg)*
Patient Height (ft)*
Patient Height (in)*
Patient Weight (lbs)*
Height in Inches (Calculated)
Patient BMI Calculation (Metric)
Patient BMI Calculation
Patient Email (we ask you to enter it twice to ensure there are no errors)*

Confirmation EmailRe-enter your email address to confirm
Home phone*
Format: (000) 000-0000.
Cell phone
Format: (000) 000-0000.
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Country

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Where is your pain?*
Preferred communication type*
How would you prefer we contact you?
How did you hear about us?*
If you selected other, please specify how you heard about us?
What is your occupation?*

Emergency Contact

The person who will accompany you on the day of your procedure. Note that for safety reasons, you will not be permitted to drive or to leave unaccompanied after your surgery.
Contact Name*

First NameLast Name
Contact Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Relationship to Patient*
e.g. Mother
Pharmacy Contact

We need to know which pharmacy you regularly shop at, so we can coordinate with them regarding your care
Pharmacy name*
e.g. Pharmaprix
Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Fax number*
Please enter a valid fax number.Format: (000) 000-0000.

Procedures carried out

YesNo
Problems during intubationNausea and/or vomitingFeverHypotension
Please enter the name and contact information of all the medical professionals with whom you consult
Other medical conditions for which you are being followed/treated by a physician
Medical Insurance

The patient's residency and medical insurance information
YesNo
Which province/territory are you a resident of?*
Medical Card Number (RAMQ)*
e.g. (ABCD 1234 5678)
Medical Card Expiration Date*

MonthDayYear
MM-DD-YYYY

Electronic Communication and Security
I have reviewed and understand all of the risks, conditions, and instructions described in this Appendix.
Should be Empty:

Patient Questionnaire: Orthopedic surgery