History and Physical

Patient Name

Date

Height

Weight

Shoe Size

Please list all medications you are currently taking (include prescriptions, over-the-counter meds and herbal supplements):

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Please list all prior surgeries:

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Please list all prior hospitalizations (other than for surgery):

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Social History

Use of alcohol

Never No longer use History of alcohol abuse Current use

Type

How often?

Rare Occassional Moderate Daily

Use of tobbaco

Never Quit

if quit, how long ago?

Packs per day

Years

Use of recreational drugs

Never Quit Current user

Type

If quit, how long ago?

How often?

Rare Occassional Moderate Daily

Employer

Occupation

How much are you on your feet at work?

10% 25% 50% 75% 100%

Do others depend upon you for their care?

Children

Age(s)

Pets

What kind?

Elderly or disabled family member

Other

If other, please specify.

Exercise

Never

Rare

Occasional

Weekly

Several times a week

Daily

Type of exercise

Family History

Do you have a family history of:

Diabetes: Type 1 or Type 2

Cancer

Heart Disease

High Blood Pressure

Stroke

Coronary Artery Disease

Thyroid Disease

Rheumatoid Arthritis

Other

If other, please specify.

Your Medical History

Allergies

Medications

Anesthesia

Foods

Tape

Latex

Shellfish

Iodine

Other

None Known

If selected Medications, Anesthesia, Foods, or Other, please specify.

Have you ever had any of the following:

Acid Reflux

Yes No

Diabetes: Type 1

Yes No

Muscle Weakness

Yes No

Anemia

Yes No

Diabetes: Type 2

Yes No

Neuropathy

Yes No

Arthritis

Yes No

Fibromyalgia

Yes No

Open Sores

Yes No

Asthma

Yes No

Gout

Yes No

Pneumonia

Yes No

Back Troubkle

Yes No

Heart Attack

Yes No

Polio

Yes No

Balance Issues/Falls

Yes No

Heart Disease/Failure

Yes No

Rheumatic Fever

Yes No

Bladder Infections

Yes No

Hepatitis A

Yes No

Sickle Cell Disease

Yes No

Abnormal Bleeding

Yes No

Hepatitis B

Yes No

Skin Disoder

Yes No

Blood Clots

Yes No

Hepatitis C

Yes No

Sleep Apnea

Yes No

Blood Transfusion

Yes No

HIV +/AIDS

Yes No

Stomach Ulcers

Yes No

Bronchitis/Emphysema

Yes No

High Blood Pressure

Yes No

Stoke

Yes No

Cancer

Yes No

High Cholesterol

Yes No

Hyperthyroid

Yes No

Circulation Disorder

Yes No

Kidney Disease

Yes No

Hypothyroid

Yes No

COPD

Yes No

Liver Disease

Yes No

Tubercolosis

Yes No

Depression

Yes No

Low Blood Pressure

Yes No

Tremors

Yes No

Memory Loss

Yes No

Migraine Headaches

Yes No

Mitral Valve Prolapse

Yes No

To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and the office staff of any changes in my medical status.

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.

Name of Patient, Parent, or Guardian

Signature of Doctor

If other than patient, relationship to patient.

Date

Signature

Date

Current Problem

What specific problem brings you to our office today?

Where is the pain/problem located?

Left Foot

Top of foot

Bottom of foot

Inside of foot

Outside of foot

Right Foot

Top of foot

Bottom of foot

Inside of foot

Outside of foot

How long ago did this problem first start?

Did your pain or problem

Begin all of a sudden Gradually develop over time

How would you describe your pain?

No pain

Sharp

Dull

Aching

Burning

Radiating

Itching

Stabbing

Other

If other, please specify.

Since the time your pain or problem began, has it:

Stayed the same Become worse Improved

If other, please specify.

What makes your pain or problem feel better?

What treatments have you had for this problem?

How has this problem affected your lifestyle of ability to work?

Was this caused by an injury?

Yes No

If yes, describe.

If yes, was it a work-related injury?

Yes No

If diabetic, most recent A1C

Most recent blood sugar reading

Medication Allergies

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