INTAKE FORM

Name:

DOB:

Height:

Weight:

Shoe Size:

Allergies:

If no allergies check box

Medications:

Past Medical History:

Surgical History (last five years):

Marital status:

M D S

Who do you live with?

How many children?

Are you pregnant?

Yes No Could be

Employment:

Unemployed Disabled Retired Employed

Occupation (current or former):

Smoking or other nicotine use:

former current never

How many caffeinated beverages do you drink daily?

Do you drink alcoholic beverages?

Yes No

If Yes:

occasional daily less than 3 more than 3

Do you use recreational drugs? What and how often?

Family History

Please check if you have any of the following:

Fever

Chills

Headache

Eye problems

Rash

Ingrown toenails

Thick toenails

Painful calluses

Dry skin

Skin cancer

Allergies:

Drugs

Environmental

MS:

Foot pain

Foot deformity

Bunion

Hammertoes

Joint pain

Cramps in legs or feet

Neurological:

Frequent falls

Numbness

Burning

Tingling

Tremors

Urine Retention

Painful Urination

Urinary Frequency

Prostate problems

Diabetes

Thyroid problems

Wheezing

Frequent Cough

Shortness of breath

Abdominal Pain

Nausea/Vomiting

Indigestion/hearburn

Constipation

Diarhhea

Blood clotting problem poor circulation

Leg or calf pain

Night cramps

Rest pain

Vein problems

Swelling

High blood pressure

Heart attack

Stroke, murmur

Heart valve problems

Pacemaker

Anxiety

Depression

Where is your pain? Please specify where it hurts.

Right Foot:

Left Foot:

On a scale of 1 to 10 with 10 being the worst, my pain at its worst is a:

What is the quality of you pain?

Burning

Aching

Shooting

Throbbing

Other

If Other, please specify:

What caused your pain?

How long has it been bothering you?

Have you had this before?

Yes No

Did your pain come on quickly or slowly?

What makes it worse?

What makes it better?

Have you been treated for this before?

Yes No

If yes, By whom?

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

Signature:

Date:

Your information will be encrypted.