Reason For Visit
 
Name
Please describe your present foor or ankle concerns, problems, or symptoms:
Have you ever seen a podiatrist before *
If yes, for what reason? (please include who and when):
MEDICAL HISTORY
When was your last physical exam?
Physician's first and last name:
Physician's phone number: - -
Are you currently under medical treatment? *
If yes, for what:
Have you ever had any operations, especially pertaining to the legs, ankles, or feet? *
If yes, please describe:
Please highlight any of the following conditions that pertian to you: *   Pacemaker/Defibrillator
  Bypass surgery (heart or legs)
  Gall Bladder
  Orthopedic
  Joint Replacement
  Gastric bypass or lap bank
  Hear or leg stints
  Hysterectomy
  Appendix
  Catheterization
  Tonsils
  Foot/Ankle Surgery
Are you currently taking any prescriptions or over the counter medications? *
If yes, please list the
Do you smoke? *
Do you use any illegal drugs? *
Do you use alcohol? *
Current Relationship Status: *
Please highlight any of the following an immediate family member has been treated for:   Arthritis
  Cancer
  Diabetes
  Heart Disease
  High Blood Pressure
Untitled   Anemia (low blood count)
  Asthma
  Herniated disc
  Spinal stenosis
  Kidney Disease
  Liver Disease
  Low Blood Pressure
  Migraine Headaches
  Blood Clots
  Peripheral arterial disease
  Acid Reflux
  Cancer
  Chemotherapy
  Chronic Fatigue Syndrome
  Lupus
  Diabetes
  Emphysema
  Epilepsy
  Fibromyalgia
  Glaucoma
  Gout
  Hardening of Arteries
  Heart Murmur
  Heart Disease
  Hepatitis A B C D
  High Blood Pressure
  HIV/AIDS
  Mitral Valve Prolapse
  Multiple Sclerosis
  Osteoarthritis
  Muscular Dystrophy
  Phlebitis
  Sleep Apnea
  Polio
  Blindness
  Rheumatic Fever
  Rheumatoid Arthritis
  Psoriasis
  Sinus Trouble
  Skin Rash
  Stroke
  Thyroid Problems
  Tuberculosis
  Stomach Ulcer
  Varicose Veins
Please highlight if you have had any allergic reactions to the following:   Adhesive Tape
  Asprin
  Codeine
  Iodine
  Latex
  Local Anesthetics (Nocacaine)
  Penicillin
  Sulfa
  Other
If other, please explain:
Please highlight if you have or are subject to:   Burning Pain
  Chronic Infections
  Fainting
  Foot Pain at Rest
  Foot/Leg at Rest
  Foot/Legs Cramps When Walking
  Circulatory Problems
  Shortness of Breath
  Previous MRSA or VRE infection
  Chest Pain
  Bleeding/Clotting Disorder
  Cold Feet
  Foot/Leg Cramps at Night
  Nervousness
  Prolonged Bleeding
  Swelling of Legs
  Calf Pain
  Bleeding Tendancy
  Shortness of Breath when active
  Fever/Chills
  Nausea/Vomiting
Primary Pharmacy and Location