Metro Family Footcare by hcj

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									New Patient Consultation Form                                                 Metro Family Footcare
Date ___________________                                                          Medical Edge

Patient Name _____________________________ Date of Birth ______________________________


Current Problems: __________________________________________________________________________________________

__________________________________________________________________________________________________________

________________________________________________________________________________________

________________________________________________________________________________________



          Left                                                                                  Right

                                            Please use circles and
                                         arrows to indicate painful,
                                         injured, or problem area(s)



                                         PAST MEDICAL HISTORY

 Current Medication List: (Include dosage and over the counter medications)
 ________________________             ________________________            _________________________
 ________________________             ________________________               _________________________
 ________________________             ________________________               _________________________
 _____________________________        _____________________________          _____________________________

                                                  ALLERGIES

        ____ Penicillin _____ Sulfa _____ Aspirin _____Codeine _____ Iodine/Shellfish _____ Tape _____ Latex
                                     _____ Local Anesthetics _____ General Anesthetics
       Other Food or Drug Allergy: _______________________________________________________________________

 PREVIOUS INJURIES:               PREVIOUS SURGERIES:                  PREVIOUS HOSPITALIZATIONS:
 ________________                  __________________ _______________________
 ________________                  __________________ _______________________
 ________________                  __________________ _______________________


                                              SOCIAL HISTORY

 Occupation: ____________________________________                      _____ Single  _____ Married
 Athletic Activities: _______________________________                        ______ Widowed

 Alcohol: _______oz/day/week                  Current Weight: _______ Height: ________
 Tobacco: _______pks/day for____yrs           Current Shoe Size: ____________

								
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