New Patient Forms Copy | David Zhu, MD | Orthopaedic Surgery & Sports Med Specialist

New Patient Questionnaire

If you are a new patient (or haven't been seen in a while), we need to collect the following information before you can be seen. To save time at your appointment and avoid delays, please fill out and submit this form beforehand. This should take about 5 minutes to complete.

If you prefer, you can download a copy of the form, fill it out, and bring it to your appointment.

Download a copy

Name*

Date of Birth*

Your email*

Preferred Pharmacy

Primary doctor

Height*

Weight*

For the problem you are being seen for, what is your pain level on a scale of 0 to 10?*

Drug Allergies

Current Medications

Have you received the COVID-19 vaccine?*

Yes

No

If any Family History, specify family member

Tobacco/nicotine use (including cigarettes, vapes, cigars, chew, snuff, patches, gum, etc)*

Yes

No

If tobacco/nicotine use, how many packs per day?

If tobacco/nicotine use, how many years have you used tobacco products?

How many alcoholic drinks do you consume per week?*

None

Less than 7

Between 7-14

More than 14

Is this injury related to a motor vehicle accident or work injury?*

Yes

No

Previous Surgeries

Other Medical History

Glen Carbon

4802 S. State Route 159
Glen Carbon, IL 62034

Granite City

3912 Maryville Road
Granite City, IL 62040

Waterloo

509 Hamacher Street, Suite 202
Waterloo, IL 62298

David Zhu, MD

Orthopedic Surgery | Sports Medicine Specialist