PODIATRIC HISTORY

Patient's Last Name

Patient's First Name

Middle Initial

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

Have you ever been to a Podiatrist before?

Yes No

If yes, please list.

Name

Last Visit

Is there any personal or family history of diabetes?

Yes No

Your occupation

Cigarette/Tobacco use

Years smoked

Athletic activities in which you participate

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

Other

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Signature of Patient, Parent, Guardian or Personal Representative

Date

Please print name of Patient, Parent, Guardian or Personal Representative

Relationship to Patient

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