Medical History Confidential
Please complete this questionnaire as it will be used to open your file.All the information will remain confidential.All this information is required by the Quebec Podiatric law.
Full Name
*
First Name
Last Name
Cell phone
*
-
Area Code
Phone Number
Cell phone
-
Area Code
Phone Number
Work phone
-
Area Code
Phone Number
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birthday
-
Month
-
Day
Year
Date
What is your Gender?
*
Male
Female
Other
Reason of consultation
Duration of pain
Frequency of pain
Localisation of pain
Check the conditions that apply to you or to any members of your immediate relatives:
*
Asthma
Cancer
Cardiac disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Skin disease
Arthritis
Other
Were you ever hospitalize or have you undergone surgery ?
Yes
No
Which surgery and when ?
Are you currently taking any medication?
*
Yes
No
If yes, which medication
Do you have any medication allergies?
*
Yes
No
Not Sure
If yes , which allergies ?
Do you use or do you have history of using tobacco?
*
Please Select
Yes
No
Do you use or do you have history of using illegal drugs?
*
Please Select
Yes
No
How often do you consume alcohol?
*
Daily
Weekly
Monthly
Occasionally
Never
Date
-
Month
-
Day
Year
Date
Submit
Should be Empty: