PATIENT INFORMATION

Name
Nickname Sex: Male / Female
Birth Date Age
Marital Status: Single / Married / Divorced / Widowed
Address
City / State Zip
Home Phone
Work Phone
Best Time / Place to call
Email
Occupation
Employer
Address
City / State Zip
Home Phone

How did you hear about our office?

Yellow Pages / Website / Family
Friend / Physician / Insurance Plan
Other

We would like to thank them!

Name
Address
City / State Zip

INSURANCE

Insured Name
Relationship to Patient
Insured Birth Date
Is this patient covered by additional insurance? Yes No

MEDICATIONS

List all medications you are currently taking including over-the-counter products, vitamins, and herbals.

Pharmacy Name

ALLERGIES

Have you ever experienced any ALLERGIES or ADVERSE EFFECTS to any of the following?

Adhesives / Tape Yes No
Aspirin Yes No
Anti-Inflammatories Yes No
Codeine Yes No
Iodine (IVP dye) Yes No
Local Anesthetics
(Novocaine / Lidocaine) Yes No

Penicillin Yes No
Sulfa Drugs Yes No

OTHER:

MEDICAL HISTORY

Please check "YES" or "NO" to indicate if you have had any of the following:

Y N
AIDS
Arthritis
Asthma
Back Problems
Blood Clots
Cancer
Diabetes
Epilepsy
Eye Problems
Foot / Leg Cramps
Gout

Y N
Hepatitis
High Blood Pressure
High Cholesterol
Kidney Problems
Liver Problems
Parkinson's Disease
Psychiatric Problems
Stomach Ulcers
Stroke
Thyroid Problems
Are you a smoker?

OTHER:

Please list all surgeries and approximate dates:

DIABETICS

Please answer the following questions:

How many years have you been diagnosed as a diabetic?
Blood Sugar Checks: How many times each day? Average reading?

FOOT HEALTH INFORMATION

What is your current foot problem?
When did it begin?
How have you treated this problem so far?
Have you seen another doctor for this problem?
If so, whom?
Have you ever seen a foot doctor?
If so, whom?
Shoe size Height Weight

Who is your Primary Care Physician?
Date of Last Visit
Physician's Address
Phone:
Are you under regular care for any specific problem?

In case of emergency, contact:
Name: Phone:

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