PATIENT HISTORY FORM - DOC

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PATIENT HISTORY FORM
Please fill out the following confidential form for our records Patient Name: ____________________________________________ Age: _____ Height: _____ Weight: _____ Shoe Size: _____ Current Foot or Ankle Problems: _________________________________________________________________________________ ____________________________________________________________________________________________________________ When did the problem start? ____________________________________________________________________________________ What has been done to treat the problem? __________________________________________________________________________ Are you now or have you ever been under a physician’s care in the past two years? _________________________________________ If yes, please explain: __________________________________________________________________________________________ ____________________________________________________________________________________________________________ Name of Former Podiatrist: _______________________________________________________ Date last seen: _________________ What conditions were you treated for: _____________________________________________________________________________ ____________________________________________________________________________________________________________ MEDICAL HISTORY/REVIEW (Have you had or are you currently having any of the following symptoms?)  Diabetes (Please Check One: ___ Insulin ___ Non-Insulin)  Kidney or Bladder  Cancer  Bleeding Disorders  Frequent Headaches  Heart Disease  Anemia/Blood  Dizziness  High Blood Pressure  Asthma/Bronchitis  Trouble Swallowing  Stroke or Heart Attack  Rheumatic Fever  Poor Vision / Corrective Lens  Stomach Ulcer/ Reflux  Accident/Injuries  Epilepsy/Seizures  Immune Disease (HIV, AIDs)  Diarrhea  Depression/Anxiety  Thyroid Disease  Liver Disease  Black Stools  Change in Memory  Vascular/Circulatory Disease  Hepatitis  Arthritis  Trouble with balance  Swelling in Ankles/Legs  Skin Rash  Joint Aching/Pain  New Skin growths/lumps  Leg Pain – at rest  Leg Pain –walking  Swelling in Joints  Difficulty with joint motion  Gout Please explain any positive responses above: _______________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ MEDICATIONS: (Please include dosage) ____________________________________________________ ____________________________________________________ ____________________________________________________ ____________________________________________________

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ALLERGIES: (Medications, Tape, Latex, Foods, etc.)  No Known Allergies ____________________________________________________ __________________________________________________ ____________________________________________________ __________________________________________________ SURGERIES/HOSPITIALIZATIONS: (Describe procedure, year, and any complications) ____________________________________________________ __________________________________________________ ____________________________________________________ __________________________________________________ SOCIAL HISTORY: Occupation: ____________________________________________ Alcohol: __________ If yes, how much ____________________

Tobacco Use: ________ If yes, how much _______________ Illicit Drugs: _________ If yes, how much ______________

FAMILY HISTORY: (Diabetes, heart disease, gout, cancer, foot problems, other): ________________________________________ ____________________________________________________________________________________________________________ ____________________________________________________________________________________________________________ I hereby give Angel L. Cuesta, D.P.M. permission to diagnose and administer treatment for my foot condition and authorize any release of information obtained in the course of my treatment. Patient Signature: ___________________________________________________________ Date: ____________________________ Reviewed by: _______________________________________________________________ Date: ____________________________