Patient Information Form

Today's Date

Alberta Health #

Last Name

First Name

Middle Initial

Birthdate

Address

City

State

Zip

Patient Employer / School

Occupation

If Doctor, Please Specify

If other, Please specify

Contact Information

Home Phone

Work Phone

Email address

Best time to reach you

In case of emergency, Contact

Name

Relationship

Home Phone

Work Phone

Podiatric History

What is the chief complaint for which you came to be treated? (include foot, ankle, knee, thigh, and hip complaints)

Have you ever been treated by a podiatrist before?

Yes No

if yes, please list the name

Last visit

Is there any personal or family history of diabetes?

Yes No

Cigarette/tobacco use

Years smoked?

Athletic activities in which you participate(please list and indicate frequency)

Please indicate which foot problems you now have or have had in the past:

Achilles tendonitis

Yes No

Ankle sprains

Yes No

Athlete’s foot

Yes No

Bunions

Yes No

Corns and calluses

Yes No

Flat feet

Yes No

Foot or leg cramps

Yes No

Foot ulcer

Yes No

Heel Pain

Yes No

Ingrown toenails

Yes No

Limb length difference

Yes No

Neuroma

Yes No

Numbness in feet

Yes No

Plantar warts

Yes No

Swelling in ankles or feet

Yes No

Tired feet

Yes No

Medical History

PLEASE INDICATE “YES” OR “NO” IF YOU EVER HAVE HAD ANY OF THE FOLLOWING:

If Other, Please specify

Surgeries you have had

Hospitalizations other than the surgeries listed

Family Physician's Name

Phone

Add Additional Physician

Medications

Include prescriptions, over-the-counter medications and vitamins

Pharmacy Name

Pharmacy's Number

Do you take Oral Contraceptives?

Yes No

Allergies

If other, Please specify

Treatment Consent

I hereby consent and give permission to the doctor (and the doctor’s assistants or designated replacement) to administer and perform such procedures on me as the doctor deems necessary.

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 of Patient, Parent, Guardian, or Personal Representative

Relationship to Patient

Date

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