Peterborough Regional Health Centre
ORTHOPAEDIC INTAKE CLINIC
Phone 705-743-2121 ext.3203
Fax 705-876-5145
Date:_____________
Office use
REFERRAL SOURCE
MD/NP___________________________
MD OHIP Billing Number_____________
Phone: ____________________
Fax: ____________________
SURGEON
Assign next available Surgeon
REASON FOR REFERRAL
Affected Joint(s):
Hip
Knee
□YES
Patient Name: __________________________
DOB (d/m/y): __________________________
Address:_______________________________
City: __________________________________
Postal Code: ___________________________
Date:______________
Phone number: ________________________
OHIP # :_______________________________
WSIB □No □Yes
WSIB Claim #:____________________
Height:__________
Weight: ________
□NO
or
Preferred Surgeon: ________________________________
□R
□R
□L
□L
□Bilateral
□Bilateral
Diagnosis: ________________________________________________________________________
Referral Request for:
□ Conservative Treatment
□ Primary Replacement
□ Other__________________________________________
CURRENT SYMPTOMS
Pain with activity
□ MILD
□MODERATE
□ SEVERE
Pain with rest/night
□ MILD
□MODERATE
□ SEVERE
Other: ____________________________________________________________________________________________
Duration of Symptoms: _____________________________
TREATMENT
□ Acetaminophen
□ NSAID
□ Opioids
□ Steroid Injection date:_______
□ Viscosupplementation date:__________
□ Arthroscopy date:_________
□ Physiotherapy
□ Cane(s)/Walker
□ Braces
□ Exercise
□ Weight Loss
□ Other: ________________________
PMHX (please note, or attach complete EMR profile):
Cardiovascular_________________RESP______________ENDOCRINE___________GI___________HEENT__________
GU___________MSK_____________NEURO______________AUTOIMMUNE_____________OTHER_______________
_________________________________________________________________________________________________
ALLERGIES □ NO
□ YES List_____________________________________________________________________
Please attach complete current medication list
X-RAY REPORT TO BE ATTACHED (WITHIN 6 MONTHS) MRI not required, and will be recommended if needed.
Clinical Question: Query Osteoarthritis
Knee: Views: bilateral PA Standing , bilateral PA Standing 30° Flexion, affected Lateral, and affected Skyline
Hip:
Views: AP pelvis, affected AP Hip, Lauenstein view (lateral)
Orthopedic intake clinic referral form Draft
Orthopedic intake clinic referral form Draft