Medical History Information

Please correct the errors described below.

Name

Please explain the reason for your visit. (In Detail)

How long have you been bothered by this condition?

Days

Weeks

Months

Years

Have you ever been treated for this condition before

Yes No

If YES by whom:

If NO what have you used to improve the symptoms?

Have you ever had any previous FOOT surgeries?

Yes No

Add new row

Have you ever been hospitalized in the past five years? (Other than Surgery)

Have you ever had orthotics?

Are you allergic to any medications, foods, tape, latex etc..?

Are you taking any Medications, Vitamins, Herbs, Cold pills, Remedies, Stimulants, Steroids, Birth control, Diet pills, Nontraditional medicines, Over the counter medicines, etc..? (Explain all that apply)

Do you smoke Cigarettes?

Yes No

If Yes how much and how long.

Do you drink Alcohol?

Yes No Occasionally

Do you use Recreational Drugs? Marijuana, Cocaine, Crack, Heroin, Ecstacy, GHB, Mushrooms, LSD, Speed, etc.. (Explain all that apply)

PLEASE CHECK THE APPROPRIATE BOXES THAT APPLY TO YOU.

Arthritis

Asthma

Cancer

Heart Disease

Heart Attack

Stomach Ulcers

High Blood Pressure

Rashes

Seasonal Allergies

Kidney Disease

Thyroid Disease

Diabetes

Sickle Cell Trait/Anemia

Hemophilia

High Cholesterol

Vascular Disease

Pulmonary Embolus

HIV

Strokes

Hepatitis B or C

Psychiatric Illness

Varicose Veins

Keloids

Leg/Foot Ulcers

Bleeding Disorders

Cataracts

Hypertrophic Scars

Please explain all checked answers.

Your information will be encrypted.

Electronic signature

Your browser does not support capabilities required for electronic signatures.

Loading templates...

Use existing signature
Type the signature
Draw
Upload an image

Click a signature you want to use:

Clear

Drop image file here or click to select file Click here to select image file from your computer

I request that my signature be represented by the above electronic signature and consent to recipients of electronic documents that I sign receiving personal information about me, including my email and IP addresses.

Use this signature or Cancel

Hushmail

Hide