Patient Information

Patient’s Name: ______Date of Birth: ______Age: _____

Address: ______City/State/Zip: ______Sex: M / F Marital Status: ______SSN: ______

Occupation: ______Employer: ______

Business Address: ______

May we leave a message?

Home Phone #: ______Yes No

Cell Phone #: ______Yes No

Work Phone #: ______Yes No

E-mail: ______Yes No

Which is your primary contact number: ______Primary Language: ______

Emergency Contact: ______Relationship: ______Phone: ______

Secondary Contact: ______Relationship: ______Phone: ______

Is there a family member or other person you would like us to share medical information with?

Name(s): ______

Primary Care Doctor: ______Last Visit: ______Phone: ______

Pharmacy: ______Location: ______Phone: ______

Former Podiatrist: ______City/State: ______

Who is Financially Responsible for Payment: ______

Address: ______City/State/Zip______Phone: ______

Who referred you to us: ______

Medications - Please list all you are currently taking (Including prescriptions & over-the-counter meds):

______

Family History – Please indicate which relatives have a history of the following problems.

Arthritis ______High Blood Pressure ______

Cancer ______Kidney Stones ______

Diabetes ______Mental Disease ______

Heart Disease ______Stroke ______

Patient’s Name ______

What specific problem brings you to our office today? ______

______

Your Medical History

Have you ever had any of the following?

Do you Drink / Y / N / Stomach Ulcers / Y / N / Anxiety / Y / N
Do you Smoke / Y / N / Diarrhea/Constipation / Y / N / Mental Illness / Y / N
Diabetes / Y / N / Bladder Infections / Y / N / Mentally Disabled / Y / N
Vision Loss / Y / N / Urinary Tract Problems / Y / N / Kidney Disease / Y / N
Hearing Loss / Y / N / Arthritis / Y / N / Thyroid Disease / Y / N
Hypertension / Y / N / Gout / Y / N / Liver Disease / Y / N
Heart Attack / Y / N / Fibromyalgia / Y / N / Hepatitis / Y / N
Heart Disease/Failure / Y / N / Back Pain / Y / N / Anemia / Y / N
Sleep Apnea / Y / N / Skin Disorder / Y / N / Swelling / Y / N
Asthma / Y / N / Headaches / Y / N / Abnormal Bleeding / Y / N
Bronchitis/Emphysema / Y / N / Neuropathy / Y / N / Blood Clots / Y / N
Pneumonia / Y / N / Stroke / Y / N / Blood Transfusions / Y / N
Tuberculosis / Y / N / Falling/Poor Balance / Y / N / Cancer / Y / N
Acid Reflux / Y / N / Depression / Y / N / HIV/AIDS / Y / N
Other Conditions:

Allergies: □ No Known Allergies

□ Medications ______

□ Anesthesia ______□ Foods ______

□ Tape □ Latex □ Shellfish □ Iodine □ Other ______

For Women only, are you pregnant No Yes How many months ______

List any Surgeries: ______

______

List any Hospitalizations: ______

______

Any Other Important Information: ______

______

Shoe Size ______Height ______Weight ______Hours on feet per day______

Circle activities in which you participate: Walking / Jogging / Bowling / Tennis / Hiking / Golf / Biking / Baseball

Basketball / Football / Exercise at Gym / Other ______

Patient’s Signature ______Date ______