FOOT AND ANKLE CENTER OF ILLINOS

Patient's Name

Date of Birth

Account #

Age

SSN #

Email address

Address

City

State

Zip Code

Height

Weight

Blood Pressure

BMI

If other language, please specify

Work Phone

Home Phone

Cell Phone

Marital Status

Single Partnered Married Divorced Widowed

Children

Yes No

Ages

If other living situation, please specify

Occupation

Name of your employer

Is this a work-related injury?

Yes No

Family / Primary Doctor

Doctor who referred you to FACI

Preferred Pharmacy

Reason for today’s visit:

PERSONAL HEALTH HISTORY

Current/Chronic Medical Problems (e.g., diabetes, hypertension, high cholesterol)

Add additional Illness

Past Surgeries

Add Additional Surgeries

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Add Additional Drugs

Allergies to medications

Add Additional Allergies

HEALTH HABITS AND PERSONAL SAFETY

TOBACCO

Do you use tobacco?

Yes No

How Much?

# of years?

Year Quit?

IMAGING

Have you had X-rays, MRI or CT for this problem?

Yes No

If yes, where?

PREGNANCY

LATEX

Are you pregnant?

Yes No

Are you allergic to latex?

Yes No

AMBULATORY AIDS

Do you use ambulatory aids?

Yes No

If other, please specify

ALCOHOL

Do you drink alcohol?

Yes No

If yes, what kind?

How many drinks per week?

DRUGS

Do you currently use recreational or street drugs?

Yes No

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Patient's Name / Signature

Date

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FOOT AND ANKLE CENTER OF ILLINOS

PERSONAL HEALTH HISTORY

Current/Chronic Medical Problems (e.g., diabetes, hypertension, high cholesterol)

Past Surgeries

List your prescribed drugs and over-the-counter drugs, such as vitamins and inhalers

Allergies to medications

OTHER PROBLEMS

HEALTH HABITS AND PERSONAL SAFETY

TOBACCO

IMAGING

PREGNANCY

LATEX

AMBULATORY AIDS

ALCOHOL

DRUGS