Online Intake Form

Request an Appointment With Wake Nonsurgical Ortho & Sports Medicine

Online Intake Form

  • Make sure to answer these questions : 1. REASON FOR VISIT(LOCATION and SIDE OF BODY) Example : Right knee pain for 3 months 2. WHEN did your problem begin? Constant, or Come and Go? 3. HOW did your problem start ? Injury or Out of nowhere ? 4. What are the symptoms (pain, locking, clicking , numbness)? 5. What makes the problem Worse? / Better ? 6. Have you had any Xrays / MRIs for this problem? If so , where and when ? 9. Were you seen in the Emergency Room for this problem ? 10. Have you seen an Orthopedist for this problem? What did they say 11. What treatment have you had for this problem?
  • DO YOU HAVE PROBLEMS WITH THE FOLLOWING: GENERAL fevers/chills  sweats  tiredness/fatigue  weight loss EYES  blurring  double vision  vision loss eye pain  photophobia ENT  ear pain/discharge  hearing problems/ringing  nosebleeds hoarseness difficulty swallowing HEART  chest pain  irregular heart beat  passing out  orthopnea  swelling in legs LUNGS shortness of breath wheezing cough  cough up blood BOWELS nausea/vomiting  diarrhea  constipation  abdominal pain blood in stool  black bowel movements URINARY burning  loss of urine  difficulty voiding  infections  blood in urine  sexual dysfunction SKIN rash itching dryness strange lesions NEUROLOGIC  weakness seizures  dizziness balance problems memory problems  MOOD depression anxiety sleep disturbance hallucinations suicidal thoughts ENDO cold or heat intolerance thirsty all the time peeing a lot large weight gain/loss BLOOD easy bruising anemia enlarged glands bleeding ALLERGY Itching frequent colds/infections HIV exposure


3237 Blue Ridge Rd.

Raleigh, NC 27612

Phone: (919) 719-2270

Mon-Fri: 8 am- 3pm

View Map