Medical History
Date:
-
Month
-
Day
Year
Date
Patient’s Name:
First Name
Middle Name
Last Name
DOB:
-
Month
-
Day
Year
Date
ALLERGIES:
No known drug allergies
Penicillin
Aspirin / Ibuprofen
Codeine
Cortisone
Tape
Sulfa
Novocain
Demerol
Iodine
Latex
Nickel / cheap jewelry
Bee Stings
OTHER
Date of last visit to primary care physician:
-
Month
-
Day
Year
Date
Females: Are you pregnant or nursing?
Yes
No
Do you use tobacco products?
Yes
Used to
Current
Never
What kind?
Cigarettes
Cigars
Chewing tobacco
Electronic cigarette
Amount:
For how long?
Does anyone in your immediate family (blood related) have DIABETES, ARTHRITIS or HEART DISEASE?
Yes
No
Who/which diagnosis
List ALL medications including non-prescription (vitamins, aspirin, etc.) & Dosage you are presently taking:
Check ANY of these health problems you have or have ever had
Rows
Current
Past
Measles
Mumps
Chickenpox
Anemia
Low Blood Pressure
Congestive Heart Failure
Bronchitis
Kidney problems (stones, failure, infections)
Blood Problems (clotting disorder)
Tuberculosis
Asthma
Emphysema
High cholesterol
Phlebitis (clots in legs)
Dizziness
Thyroid (high or low?)
Need to take antibiotics for dental visits
Mumps
Rheumatic Fever (residual complications i.e. heart murmur)
Pneumonia
High Blood Pressure
Heart Problems (abnormal rhythm, murmur, heart attack)
Liver problems (i.e. hepatitis, cirrhosis)
Circulation problems (hardening of arteries, varicose veins)
Nervous Disorders (anxiety, depression)
Back problems/injuries
Stomach Ulcer (current, resolved); Reflux/heartburn (GERD)
Arthritis (Osteoarthritis / Rheumatoid)
Epilepsy
Problems with Healing (slow healing, keloids, painful scars)
Sickle Cell
Surgical Implants (stents, heart valves, hip/knee replacement, etc.)
Diabetes
Current
Past
Type?
Auto Immune Deficiency
Current
Past
Why?
Stroke
Current
Past
Any residual effects/weakness?
Cancer
Current
Past
Type:
Gout
Current
Past
Location?
List any surgeries and/or hospitalizations in the past 10 years/when?
Do you have any other illnesses we should be aware of?
Have you seen a Podiatrist before?
Yes
No
What is the reason for your visit today?
TO MY KNOWLEDGE ALL THE ABOVE IS CURRENT AND CORRECT
Signature of Patient/ Guardian
Date
-
Month
-
Day
Year
Date
Submit
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