Section 2: Current Medical History

Patient Name:

Date:

CURRENT MEDICAL HISTORY

For each area, check all that apply:

Are you currently experiencing the following:

Fever

Chills

Headache

Malaise

Dizziness

Poor Balance

None

Eyes, Ears, Nose, Thoat

Blurred Vision

Glaucoma

Cataracts

Diabetic retinopath

Congestion

Rhinitis

Iritis

Poor Hearing

Allergies

Seasonal

Tape/Adhesives

Iodine

Latex

Metals

Drugs

Skin

Foods

If skin, please specify:

If food(s), please specify:

Musculoskeletal

Arthritis

Weakness

Fibromyalgia

Rheumatoid Arthritis

Gout

No Pain other than my feet

Neurologic

CVA

Seizures

Dizziness

Tingling

Numbness

Radiating pain down my legs

Tremor

Burning

Genitourinary

Excess frequency of urination

Burning on urination

Renal Disease

Bladder or Urinary Tract Infection

Prostate Disease

None of These

If Renal Disease is selected, please specify the stage:

Endocrine

Excessive Thirst

Excessive Hunger

Constant Fatigue

Diabetes

Hypothyroid

Other

None

If Other, please specify:

Respiratory

Wheezing

Coughing

Asthma

Pheumonia

Emphysema

Other

If Other, please specify:

Gastrointestinal

Heartburn

GERD

Nausea

Colitis

Constipation

History of stomach ulcers

None

Cardiovascular

Chest Pain

Shortness of breathe

Palpitations

Arrhythmia

History of heart attack

Chronic Heart Failure

Other

If Other, please specify:

Blood

Bleeding or clotting disorder

Other

History of Deep Vein Thrombosis or Blood Clots in your leg

If Other, please specify:

History/Poor Balance

Have fallen __ times this year

Difficulty getting out of chair

Lose balance easily when walking

Difficulty turning around while standing

Unsure of where my feet are

Unsteady going up or down stairs

Use assistive device like walker due to poor balance

If "have fallen" has been selected, please specify how many times this year:

Psychiatric

Depression Anxiety/Bipolar Schiophrenia Other

If Other, please specify:

Influenza

Date of my last flu shot:

Date of scheduled flu shot:

I don't intend to have a flu shot

History of HIV

Yes No

WOMEN: are you pregnant?

Yes No

Smoking (Check all the apply):

I don't smoke cigarettes

I currently smoke

I smoked cigarettes but no longer smoke

Chew tobacco

Smoke a pipe

If you smoked but no longer smoke, please specify for how many years:

If you currently smoke, how many packs per day and for how many years?

Alcohol (Check all the apply):

I don't drink alcohol

I seldom drink alcohol

I occasionally drink alcohol

I drink wine

I drink hard alcohol

I drink beers

If you drink wine, please specify how many glasses per day:

If you drink hard alcohol, please specify how many glasses per day:

If you drink beer(s), please specify how many glasses per day:

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

Add another surgery history

Complications from Anesthesia

Yes No

Do you currently take blood thinners?

Yes No

MEDICATION AND SUPPLEMENTS

Please list your current medications

Add another medication

Please list your drug allergies

Add another drug allergy

Pharmacy Name:

Location/Zip:

City:

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.

Patient Signature:

Date:

Date of Birth:

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

Add another foot problem

If Other, please specify:

On my:

Left Foot Right Foot

2. The problem has been present for

If other, please specify:

4. The problem began:

Gradually Suddenly Originally occasional or intermittent, then becoming more constant

If other, please specify:

8. Amount of time I spend each day on my feet

Little Moderate Extensive

If Other, please specify:

10, Overall progress since onset is:

No change

Slight improvement

Moderate improvement

Worse

Temporary improvement with therapy

11. My goals are to:

Eliminate pain

Be able to stand and walk without pain

Be able to work without pain

Exercise without pain

Return to running

Return to sports activities

Improve stability

Improve balance

12. Flu shot

Yes No

If yes, Date:

Diabetics Only

13. My fasting blood sugar today is:

14. My most recent HgA1c

Date

15. Last eye exam with ophthamologist

16. Urine tested for kidney disease

17. Have you fallen or had poor balance in the last year?

Yes No

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