Medical History Form

Please correct the errors described below.

The following information is very important to your health. Please be complete.

CURRENT FOOT/ANKLE PROBLEM

MEDICAL HISTORY

Please check only what applies for personal or family medical history of any of the following:

MEDICATIONS

ALLERGIES

WOMAN

TOBACCO

ALCOHOL

ILLEGAL DRUG USE

CONSENT

I certify that the above information is true and correct to the best of my knowledge
I give my permission for John Murphy, DPM to examine, photograph, administer and perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my foot and/or ankle problems.

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

Your information will be encrypted.

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