Sports Medicine New Patient Evaluation (Comprehensive MSK)

Date/Time: [Encounter date and time]   Patient: [Full name]   DOB: [MM/DD/YYYY]   Visit Type: Sports Medicine New Patient Evaluation   Referral Source: [Referring provider or self-referral] (Only include if applicable)   Historian: [Name/relationship; reliability] (Only include if other than patient)

Chief Complaint

[Patient-stated primary symptom, body region, laterality, and context] (Single concise line using patient's own words when available; avoid diagnostic conclusions unless presenting for management of an established diagnosis)

History of Present Illness

[Narrative description of injury context, onset timing and acuity, mechanism of injury, symptom characterization, associated symptoms, functional impact on daily activities and sport, prior evaluation and treatment to date, prior injuries to same region, patient goals and timeline pressures, pertinent red flags] (Use explicit status such as "unknown" or "patient unsure" when information is not available rather than omitting)

Injury Timeline: [Chronologic list of key injury and treatment events] (Only include for complex or recurrent patterns)

Sport and Activity History

• Primary Sport/Activity: [Sport or activity; position/role; dominant side]
• Competition Level: [recreational / club / varsity / collegiate / professional / occupational or tactical athlete]
• Season Phase: [preseason / in-season / postseason / off-season]
• Training Load: [Frequency, duration, intensity; recent changes or spikes]
• Equipment/Environment: [Footwear, orthotics, bracing, playing surface] (Only include if relevant)
• Recovery Behaviors: [Sleep quality/duration, nutrition patterns] (Only include if relevant)
• Youth Athlete Factors: [Growth spurt timing; training supervision] (Only include if applicable)
• Low Energy Availability Screen: [Menstrual function, dietary patterns, stress fracture history, weight/appearance pressures] (Include for at-risk athletes; document if screening was declined or deferred)

Past Medical and Surgical History

• Medical Conditions: [Conditions affecting healing or participation]
• Surgical History: [Orthopedic surgeries with dates; retained hardware]
• Prior MSK Injury History: [Prior injuries to same region; other major MSK injuries with dates and outcomes]
• Relevant Family History: [Early osteoarthritis, inflammatory arthritis, hypermobility, recurrent stress fractures] (Only include if pertinent)

Medications and Allergies

Current Medications: [Medication name, dose, frequency; OTC analgesic/NSAID use patterns and response; relevant supplements]

Allergies: [Drug/agent; reaction type; severity]

Social History

• Occupation: [Occupation and physical demands]
• Tobacco/Nicotine: [Use status]
• Alcohol/Substance Use: [Use status] (Only include if relevant)
• Psychosocial Factors: [Mood, fear of reinjury, external pressures] (Only include if relevant)

Review of Systems

• Constitutional: [positive / negative / not asked] for fever, chills, weight loss
• Musculoskeletal: [positive / negative / not asked] for other joint involvement
• Neurologic: [positive / negative / not asked] for numbness, tingling, weakness, bowel/bladder symptoms
• Skin: [positive / negative / not asked] for rash, warmth, erythema
• Vascular: [positive / negative / not asked] for calf swelling/tenderness

(Expand only if evaluating systemic, inflammatory, or multi-joint conditions)

Physical Examination

Vitals and General: [Vitals if obtained; pain score; general appearance; observed gait; assistive device use]

[Examined Region: e.g., Right Knee]

• Inspection: [Swelling, effusion, ecchymosis, deformity, atrophy, alignment]
• Palpation: [Specific tenderness locations; warmth; crepitus]
• Range of Motion: [Active/passive ROM; pain arc; degrees]
• Strength: [Muscle groups tested; 0-5 grading; note if pain-inhibited]
• Neurovascular: [Sensation; motor function; pulses if indicated]
• Special Tests: [Test name: positive / negative / equivocal; symptom reproduction] (Document each test by specific name)
• Functional Testing: [Task-based movements performed and findings]
• Contralateral Comparison: [Symmetry findings; baseline laxity]
• Exam Limitations: [Maneuvers deferred and reason] (Only include if applicable)

(Repeat regional examination structure for each region examined)

Diagnostics

• Imaging Reviewed: [Study type; date; facility; key findings; independent interpretation vs radiology report]
• Imaging Obtained Today: [Views; preliminary findings]
• Imaging Ordered: [Modality; body part; indication]
• Clinical Decision Rules: [Rule applied; criteria findings] (Only include if used, e.g., Ottawa Ankle Rules)

(If no imaging reviewed or ordered, state explicitly)

Assessment

(List problems in order of clinical priority; use qualified terms such as "suspected" or "consistent with" when diagnosis is not established)

[Problem 1: Diagnosis with laterality and acuity]

• Mechanism: [traumatic / overuse / insidious]
• Supporting Evidence: [Key history, exam, and diagnostic findings]
• Differential: [Alternative diagnoses in descending likelihood] (Only include if diagnosis not established)

(Repeat for additional problems)

Plan

(Organize by problem; include only applicable elements)

[Problem 1 Plan]

• Diagnostics: [Tests ordered with rationale]
• Medications: [Name; dose; frequency; duration; relevant counseling]
• Rehabilitation: [PT referral or home program; key targets; precautions]
• Activity Modification: [Allowed activities; restrictions; cross-training options; weight-bearing status]
• Bracing/DME: [Device type; duration; wear schedule]
• Procedures: [Considered or performed; reference separate procedure note if applicable]
• Referrals: [Specialty and indication]
• Education: [Diagnosis explanation; expected course; warning signs]

(Repeat for additional problems)

Return-to-Sport Status

• Clearance Status: [not cleared / cleared with restrictions / full clearance]
• Current Restrictions: [Specific activity limitations and allowed activities]
• Progression Criteria: [Objective criteria for advancement: ROM, strength symmetry, functional tests]
• Supervision: [PT / ATC / physician / self-directed]
• Timeline Considerations: [Competition dates and how recommendations were tailored] (Only include if applicable)

Follow-up

• Interval: [Timeframe or milestone-based]
• Contingency Triggers: [Symptoms or findings prompting earlier reassessment]
• Communication: [Summary sent to athletic trainer, coach, or referring provider] (Only include if applicable)