History of Present Illness
PLEASE TAKE A FEW MINUTES TO COMPLETE THIS FORM
This information will help the doctor diagnose and treat your problem with the most efficiency.
Patient Name:
DOB:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reason for today’s visit:
Where specifically is the problem?
How would you describe the symptoms? (sharp pain, dull pain, achy, throbbing, burning, etc; if painful use a scale from 0 none -10 terrible)
Only present at certain times? (when press on it, when walk on it, constant)
When did it begin?
Did it begin suddenly or slowly evolve?
What started the symptoms? (injury, change in activity or footwear, new exercise program, etc)
Is the condition improving, worsening or staying the same since it began?
What have you done to treat it/what has helped? (nothing, rest, heat, ice, massage, shoe inserts for cushion or arch support, change of shoegear, anti-inflammatories such as Advil, OTC remedies, etc.)
Has this ever occurred before and how was it treated?
Any other information that you think the doctor should know about your problem?
Signature of Patient/ Guardian
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name if not patient signing:
Submit
Should be Empty: