mbpodiatryla.com - Medical Questionnaire

Height

Weight

Are you currently having or have you recently had any of the following problems?

Constitutional

	Yes	No
Recent weight loss
Recent fevers or chills
Night sweats
Difficulty sleeping

Ears, Nose, Throat

	Yes	No
Hearing loss
Ringing in ears
Sinus problems
Sore throat
Active dental issues
Wear hearing aids or dentures

Cardiovascular

	Yes	No
Irregular heart beat
Chest pain, angina
Bleeding problems
Blood clots
Swelling arms or legs

Respiratory

	Yes	No
Shortness of breath
Cough
Breathing difficulties

Gastrointestinal

	Yes	No
Heartburn
Nausea and /or vomiting
Changes in bowel habits
Blood in bowel movements

Musculoskeletal

	Yes	No
Joint pain
Limb pain
Muscle weakness
Difficulty moving arm /leg
Swelling limb/joint

Eyes

	Yes	No
Wear glasses or contacts
Cataracts
Glaucoma
Vision problems

Skin

	Yes	No
Psoriasis or eczema
Open sores or cuts
Dermatitis - rash

Neurologic

	Yes	No
Headaches
Dizziness
Falls
Memory problems
Balance problems
Numbness/tingling

Endocrine

	Yes	No
Diabetes
Thyroid disorder

Cancer

YesNo

What kind?

Genitourinary

	Yes	No
Frequent bladder infections
Painful urination
Difficulty starting urination
Blood in urine

Mental Health

	Yes	No
Depression
Anxiety

Other (List)

Patient signature

Date

Reviewed by

Provider #

Date

Time

Hour Minutes

AM/PM Option

	Acute Medication	Dose	Frequency	Current Medication	Dose	Frequency
1
2
3
4
5
6
7
8

	Select	What reaction did you have?
None
Penicillin
Sulfa
Iodine
Latex
Contrast dyes
Adhesive tape

	Alive/Deceased	Age	Health Status/Cause of Death
Mother
Father
Sibling
Sibling
Sibling

Medical Questionnaire - Adult

Your Current Problem

Social History

Past Medical History

Past Surgical History

Medications Acute/Current List

Allergies

Family History

Review of Systems/Current Symptoms