PATIENT HISTORY CURRENT DATE ______________

# _____________ UP-DATE ____________________

This information is required by your insurance company.

NAME _________________________________________________ PHONE (_______)_________________________

S S # ___________________________________ ADDRESS ______________________________________________

AGE _______ BIRTH DATE _______________ CITY _____________________ STATE _____ ZIP ______________

MARITAL STATUS: S M D W # CHILDREN ______ SHOE SIZE _______ SEX: M F RACE ________

HEIGHT ___________ WEIGHT __________ B/P ________________ PULSE _____________

SPOUSE/ PARENT NAME _____________________________________________ BIRTH DATE _________________

SOCIAL SECURITY # __________________________________________________

PATIENT’S OCCUPATION ______________________________ EMPLOYER __________________________________

WORK ADDRESS ___________________________________ CITY _________________ STATE ____ ZIP __________

WORK PHONE (________)______________________ EXT _________

PERSON RESPONSIBLE FOR PAYMENT ___________________________

NAME OF MEDICAL INSURANCE _________________________________ / __________________________________

REFERRED BY ____________________________________________________ Friend Newspaper Phonebook

FORMER PODIATRIST ______________________________________________

PRIMARY CARE PHYSICIAN _______________________________________ LOCATION _____________________

OTHER DOCTOR __________________________________________________ SPECIALITY ____________________

DO YOU SMOKE?................................. YES NO

ARE YOU DIABETIC? ......................... YES NO If yes, year diagnosed ___________

DO YOU HAVE ALLERGIES?.............. YES NO If yes, please mark those you are allergic to and the reaction:

___ Penicillin ___ Sulfa ___ Tape

___ Aspirin ___ Motrin ___ Codeine

___ Novocaine ___ Demerol ___ Morphine

___ Cortisone ___ Iodine ___ Shrimp/Sea food

Other ALLERGIES: ___________________________________________________________________________

MEDICAL PROBLEMS: CURRENT MEDICATIONS:

____________________________________________ ______________________________________________

OVER THE COUNTER MEDICATIONS/ VITAMINS: WOMEN: Are you Pregnant? YES NO

____________________________________________ Planning a pregnancy? YES NO

____________________________________________

DO YOU HAVE A VASCULAR BY-PASS? YES NO Location: ________________________

DO YOU HAVE JOINT IMPLANTS? YES NO Location: ________________________

DO YOU HAVE REPLACEMENT HEART VALVES? YES NO

WHAT IS YOUR FOOT PROBLEM TODAY? __________________________________________________________

_________________________________________________________________________________________________

DURATION OF PROBLEM _____________________ IF AN INJURY, DATE OCCURRED __________________

PLEASE LIST ALL PAST SURGERIES YOU HAVE HAD:

PAST SURGERIES YEAR PAST SURGERIES YEAR

________________________________________________|__________________________________________________

PAST MEDICAL HISTORY--- CHECK ( ) THOSE YOU HAVE BEEN TREATED FOR...

_____ Diabetes	_____ Kidney Disease	_____ Urinary Problems
_____ High Cholesterol	_____ Cancer	_____ Prostate Disease
_____ High Blood Pressure	_____ Gout	_____ Bowel /Colon Problems
_____ Heart Condition	_____ Rash/Skin Problems	_____ Anemia
_____ Chest Pain	_____ Arthritis	_____ Keloid/Thick Scar
_____ Heart Attack	_____ Stomach Problems	_____ Allergies/Hay Fever
_____ Stroke	_____ Stomach Ulcers	_____ Hearing Problems
_____ Poor Circulation	_____ Lung Disease	_____ Rheumatic Fever
_____ Frequent Infections	_____ Tuberculosis	_____ Glaucoma
_____ Liver Disease	_____ Asthma	_____ Macular Degeneration
_____ Hepatitis		_____ HIV/AIDS

FAMILY HISTORY: Please mark if your family had any of these:

Mom Dad Bro/ Sis

Heart Condition . . . . . . . _____ _____ _____

High Blood Pressure . . . _____ _____ _____

Stroke . . . . . . . . . . . . . . . _____ _____ _____

Cancer . . . . . . . . . . . . . . _____ _____ _____

Diabetes . . . . . . . . . . . . . _____ _____ _____

Bleeding Disorder . . . . . _____ _____ _____

Kidney Disease . . . . . . . _____ _____ _____

SOCIAL HISTORY:

Check those you use ...

_____ Cigarettes How many packs/day? ___ If you quit, what year? ______

_____ Chewing Tobacco

_____ Cigars or Pipe

_____ Alcohol (beer, wine, mixed drinks) How much in an average week? ___________

_____ Drugs (marijuana, cocaine, or others) How often? ____________

_____ Coffee/tea Cups per day __________

_____ Pepsi/Coke/Soft drinks Cans per day __________

Type of regular exercise done: _____________________________ Hours each week _____________________

PHARMACY _________________________________________ CITY ______________________________

CONTACT PERSON __________________________________________ PHONE ______________________ hm wk

Spouse Relative ______________________ Friend

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