Medical History Form

Reason for Today’s Visit

Patient’s Last Name:

First Name:

MI:

Date:

Please describe current problem:

Which lower extremity:

Left Right

How long has this problem troubled you:

Have you undergone previous treatment for this problem:

Yes No

If yes, please describe:

Is your problem a result of injury:

Yes No

If yes, date of injury:

Did injury occur while at work:

Yes No

Medications (prescription and nonprescription medications)

Add medication

Allergies

Please indicate:

No known allergies Yes, please list below (medication, food, materials etc.)

Add allergy

Medical History (please check all that apply)

Arthritis/Bone-Joint Problems

Yes No

Anemia

Yes No

Asthma/Breathing/Lung Problems

Yes No

Back Problems

Yes No

Bleeding Problems

Yes No

Blood or Blood Product Transfusion

Yes No

Blood Clots

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Chest Pain/Heart Problems

Yes No

Circulatory Problems

Yes No

Diabetes

Yes No

Dropfoot

Yes No

Ear/Nose/Throat Problems

Yes No

Eye Problems

Yes No

Gout

Yes No

Gynecological Problems (Females)

Yes No

Head and Neck Problems

Yes No

Heart Attack

Yes No

If yes, please provide date:

Hepatitis/Jaundice/Liver Disease

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Lower Extremity Wounds

Yes No

Lyme Disease

Yes No

Neuromuscular Disease

Yes No

Numbness or Weakness

Yes No

Other Serious Illnesses

Yes No

Pacemaker

Yes No

Polio

Yes No

Positive Culture for MRSA/VRE

Yes No

Positive Test for HIV

Yes No

Previous Diabetic Foot Wounds

Yes No

Prostate Problems (Males)

Yes No

Psychiatric/Emotional Disorder

Yes No

Recent Weight Gain/Loss

Yes No

Seizures/Epilepsy

Yes No

Sickle Cell Disease or Trait

Yes No

Skin Problems

Yes No

Stroke

Yes No

If yes, please provide date:

Stomach/Intestinal Problems/Ulcers

Yes No

Tetanus Immunization

Yes No

If yes, please provide date:

Thyroid Problems

Yes No

Tuberculosis

Yes No

Urinary Tract Problems

Yes No

Venereal Disease

Yes No

Family History

Father:

Living Deceased

Mother:

Living Deceased

Siblings: indicate # of siblings

Does or did anyone in your immediate family have any of the previously mentioned medical problems:

Yes No

If yes, please describe:

Surgical History

Previous foot or ankle surgery:

Yes No

If yes, please specify:

Right Left

If yes, please describe:

Previous surgery other than foot or ankle:

Yes No

If yes, please describe:

Have you ever had any anesthetic agents:

Yes No

If yes, please indicate:

General Spinal Epidural Sedation Local Regional

Please describe any complications:

Do you have any internal metal, vascular or other implants (pins, grafts, screws, plates, clips, joints, etc.):

Yes No

If yes, please describe:

Personal History

Do you smoke:

Yes No

If yes, how much?

Do you drink alcohol:

Yes No

If yes, how often:

Are you pregnant or breast feeding (females):

Yes No

If no, are you trying to become pregnant:

Yes No

Do you participate in physical fitness activities:

Yes No

If yes, please describe:

Are you:

Right handed Left handed Both

Weight:

Height:

Do you use:

Cane

Walker

Brace

Crutches

Wheelchair

Prosthesis

Shoe size:

Shoe width:

What type of shoes do you wear:

If there is additional information that you think the doctor should know, please describe below.

Your information will be encrypted.