Medical History Form

History & Medical Information

Patient Name:

Left

Right

1. Explain your foot/ankle problem:

2. When did pain/discomfort begin (date):

Days?

Weeks?

Months?

Describe your pain/discomfort:

Burning Numbness Sharp Other

If Other, Please specify:

3. What makes the pain/discomfort better?

Have you had a physical trauma or an accident?

Yes No

If yes, please explain:

5. Occupation:

Is your problem work related?

Yes No

8. Allergies

None

Penicilin

Anesthesia

Aspirin

Sulfa

Codeine

Demerol

Mycins

Tape

Other

9. Surgical History: Have you had surgery?

Yes No

10. Social History: (only mark was is pertinent to you)

Tobacco Use

Caffeine Use

Alcohol Use

Drug USe

Exercise Habits