Section 2: Current Medical History

Foot & Ankle Center of Lake City

Please correct the errors described below.

CURRENT MEDICAL HISTORY

For each area, check all that apply:

Influenza

List all the surgeries you've had in the last 5 years

Add another surgery history

MEDICATION AND SUPPLEMENTS

Please list your current medications

Add another medication

Please list your drug allergies

Add another drug allergy

To the best of my knowledge, all the preceding answers of my medical history and medications and supplements list are true and correct. If I have any changes in my health history or medications and supplements, I will inform the doctor at my next appointment.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

What are the top 3 foot problems you wish to discuss with Dr. Berg today?

Add another foot problem

Diabetics Only

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