FOOT AND ANKLE CENTER OF WEST TEXAS

BRIAN K. MIDDLEBROOK, DPM

Patient Name

DOB

Review of Systems

As you review the list, please circle any of the problems which have significantly affected you.

Constitutional

Recent weight gain

Recent weight loss

Fever

Nausea/Vomiting

Weight Gained

Weight Lost

Current Weight

Height

Musculoskeletal

Joint pain

Joint swelling/redness

Stiffness

Lower extremity pain

Burning/ Tingling/ Strange Sensations

Cramping of feet or legs

Integumentary

Rash

Calluses/Corns/ Lesions

Discolorations in skin /Nails

Primary Physician

MEDICAL HISTORY

If Autoimmune Disorder, kindly specify.

If Other, please specify.

Are you diabetic?

Yes No

How long?

Name of treating physician

Are you on dialysis?

Yes No

How long?

Name of treating physician

Previous Surgeries

Previous Foot History: Have you had:

Fractures?

Yes No

Where

Gout?

Yes No

Treatment

Fungus?

Yes No

Treatment

Diabetic Foot Wounds?

Yes No

What size shoes do you wear?

Family History: Any blood relative (limited to parents, grandparents, siblings, children) have:

Foot problems

Diabetes

Heart Disease

High Blood Pressure

Social History

Do you drink alcohol?

Yes No

How many times a week?

Do you drink caffeine?

Yes No

How many cups per day?

Do you use tobacco products including vaping?

No Yes Quit

How many years?

Do you use recreational drugs for non medical purposes?

Yes No

Do you exercise regularly?

Yes No

What type

Do you sleep well at night?

Yes No

Why not

MEDICATIONS

Add new row

Allergies

Please list any medications you are allergic to:

Add new row

Preferred Pharmacy

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