Medical History Form

Please complete the following information which will assist in determining an accurate diagnosis and proper course of treatment.

Patient's Name (Last, First, Middle Initial)

Today's Date:

DOB:

Age:

Height:

Weight:

Shoe Size Specifications:

Have you had previous treatment by a podiatrist?

Yes No

When:

For What:

Is this a doctor referral?

Yes No

Dr:

Clinic Name and Location:

Name of Family Physician:

Clinic Name and Location:

Are you currently under your physician's care?

Yes No

If yes, for what?

Date Last Seen:

What pharmacy do you prefer?

My foot problem involves my:

RIght Foot

Left Foot

Both Feet

Date of (Onset / Injury )

Describe your foot problem:

Surgeries you have had:

Hospitalization other than for the surgeries listed:

Medications:

Add another medication

NURSING NOTES

Blood Pressure:

Smoking History:

Non- Smoker

Current Smoker

Former Smoker

Family History:

Occupation:

Other Findings:

Add new row

ALLERGIES

Are you allergic to or sensitive to:

Novocaine

Yes No

Reaction:

Penicillin

Yes No

Reaction:

Adhesive Tape

Yes No

Reaction:

Materials

Yes No

Reaction:

Drugs

Yes No

Reaction:

Foods

Yes No

Reaction:

Latex

Yes No

Reaction:

Betadine

Yes No

Reaction:

Other (if so describe)

DIABETIC HISTORY

Insulin Dependent

Oran Medication

Diet Controlled

Average Blood Sugar

Last Hemoglobin A1C

Dosage of Insulin (per day)

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