TTUHSC-Department of Orthopedic Surgery

TTUHSC-Department of Orthopedic Surgery

Foot Service PATIENT QUESTIONNAIRE

What brings you here today:______

Where does it hurt?______

Was this the result of an injury? ☐Y / ☐N Date of injury? Is there a legal claim? ☐Y / ☐N

Where did the injury occur? ☐ Home ☐ School ☐ Work ☐ Auto ☐ Other______

Symptoms: ☐Pain ☐Swelling ☐Numbness ☐Ulcer ☐Cramping ☐Lumps ☐Calluses

On a scale of 1-10, how severe is the pain? No pain 1 2 3 4 5 6 7 8 9 10 Worst pain ever

When is the pain? ☐ Constant ☐ Frequently ☐Occasionally ☐ Rarely ☐Daytime ☐Nighttime

How long have you had the problem? Days Weeks Months Years

Are the symptoms: ☐ getting worse ☐ staying the same ☐ improving

What makes it better?______What makes it worse?______

Please describe the type of pain you have (circle all that apply)

Sharp Aching Stabbing Pins and needles Comes and goes

Dull Cramping Throbbing Constant Burning

Do you have problems walking on: ☐ Stairs ☐ Ramps ☐ Rough ground ☐ All surfaces

Do you wear: ☐Dress shoes ☐Athletic shoes ☐Custom shoes or a brace ☐Orthotics or insert

How far can you walk?______Do you use a: ☐ Cane ☐ Walker ☐ Crutches

Who is your primary care provider?______

Review of Systems -- Please circle any of the following you have experienced recently:

General: Fever, Chills, Sweats,Weakness

Eye: Drainage, Blurry Vision, Double Vision

Head: Hearing loss, Ear pain, Nasal congestion, Sore throat, Sinus pain, Neck stiffness

Lungs: Short of Breath, Cough, Bloody sputum, Wheezing

Heart: Chest pain, Racing heart, Leg swelling, Fainting, Difficulty lying down

Stomach: Nausea, Vomiting, Diarrhea, Constipation, Heartburn, Stomach pain

Urinary: Burning, Discharge, Incontinence

Blood: Easy bruising, Excessive bleeding, Anemia, Blood Clot

Endocrine: Excessive thirst, Cold or Heat Intolerance

Immunologic: Recurrent fevers, Recurrent Infections

Musculoskeletal: Back pain, Neck pain

Skin: Rash, Sores that won’t heal, Changes in Mole

Nerves: Balance problems, Confusion, Numbness, Tingling, Headache

Psychiatric: Anxiety, Depression

Other recent problems not listed above?______

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Your height:______Your weight:______

Past Medical History -- Please circle any of the following you have had

High blood Heart problems Bleeding Blood clots Varicose

pressure problems phlebitis veins

Emphysema Pneumonia Tuberculosis Asthma Irregular heartbeat

Stroke Diabetes Psoriasis Gout Kidney failure

Lupus Rheumatoid Urinary Gallbladder Anesthesia

arthritis infections problems problems

Cancer Ulcers Sleep Apnea Psychiatric Thyroid

Other Serious Medical problems?______

Do you have any allergies? ______

Family History (mother, father, brother, sister) has had

☐ Arthritis ☐ Diabetes Mellitus ☐ Heart problems ☐ Anesthesia problems

☐ Bleeding problems ☐ Blood clot ☐ Foot problems

Social History

Do you drink alcohol? ☐ No ☐ Yes (how many drinks per week?)______

Do you smoke? ☐ No ☐ Yes – How many per day?______How long?______

What is your occupation? (Grade if in School)______

Please list any medications you are now taking, prescription and over the counter

Name of medication Dosage (example 10mg.) How often do you take it

Please describe any past surgeries

______

Thank you.

Reviewed:______Date:_____

Updated:______Date:______

Updated:______Date:______

Updated:______Date:______