Medical History

1. Do you have or have you had any of the following conditions?

Diabetes

Yes No

Asthma

Yes No

Rheumatic Fever

Yes No

Hepatitis

Yes No

Glaucoma

Yes No

Seizures

Yes No

High Blood Pressure

Yes No

Artificial Joint/Valve

Yes No

Immunosuppression

Yes No

Organ Transplant

Yes No

Heart Disease

Yes No

Chest Pain

Yes No

Pneumonia

Yes No

Kidney Disease

Yes No

Cancer

Yes No

Stroke

Yes No

Emphysema

Yes No

Other

2. List any past illness or surgery for which you were hospitalized.

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3. List and describe any allergies to medications and other substances.

4. List any current medications (include prescription and non-prescription drugs)

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5. Do you use Tobacco?

Yes No

If yes, how much?

6. Do you use Alcohol?

Yes No

If yes, how much?

7. Have you received a blood transfusion?

Yes No

If yes, when?

8. Have you had a recent weight loss?

Yes No

If yes, how much?

9. What is the reason for today’s visit?

Central Connecticut Foot Care Center, LLC Disclosure Agreement

Print name of patient

Relationship to patient

Example: self, father, mother, legal guardian, other (specify)

Do you give our office permission to discuss your medical information with family members?

Yes No

If yes, please provide us with names and phone numbers below:

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May we leave personal medical information on your:

Answering Machine?

Yes No

Cell Phone Voice Mail?

Yes No

May we e-mail personal medical information to you?

Yes No

E-mail Address

My signature below indicates I have received and/or reviewed a copy of the Privacy Practice Policy of this office and have agreed to the release of my health information as indicated above.

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

Patient or Responsible Party Signature

Date

Your information will be encrypted.