Date
Patient Name: ________________________________________________________ Date of Birth ___/____/___
First M Last
GENERAL ALLERGIES ( No Allergies
( Adhesive/Tape ( Local Anesthetics ( Nickel ( Latex ( Shellfish
DRUG ALLERGIES:____________________________________________________________________
MEDICATIONS ( No Medications
Please list all your current prescriptions, including over-the-counter medications and vitamins: _____________________________________________________________________________________________________________________________________________________________________________________
PATIENT and FAMILY’S PAST MEDICAL HISTORY
Check all that apply to the patient (P) and/or to family blood relatives Mom (M), Father(F),Sis (S), Bro (B):
|P |M M |F |S |B | |P |M |F |S |B | |P |M |F |S |B | |Acid Reflux | | | | | |Cancer | | | | | |Malignant Hyperthermia | | | | | | |AIDS/HIV | | | | | |Chemical Dependency | | | | | |Osteoporosis | | | | | | |Alzheimer’s | | | | | |Chest Pain | | | | | |Peripheral Neuropathy | | | | | | |Anemia | | | | | |Circulatory Problems | | | | | |Phlebitis | | | | | | |Migraines | | | | | |Diabetes | | | | | |Psychiatric Care | | | | | | |Anxiety | | | | | |Epilepsy | | | | | |Radiation Treatment | | | | | | |Arthritis | | | | | |Fainting | | | | | |Raynaud’s Disease | | | | | | |Rheumatoid Arthritis | | | | | | | | | | | |Respiratory Disease | | | | | | |Artificial Heart Valves | | | | | |Fibromyalgia | | | | | |Rheumatic Fever | | | | | | |Artificial Joints | | | | | |Gout | | | | | |Reflex Sympathetic Dystrophy | | | | | | |Asthma | | | | | |Heart Disease | | | | | |Shortness of Breath | | | | | | |Back Problems | | | | | |Hepatitis | | | | | |Stroke | | | | | | |Bleeding Disorders | | | | | |High Blood Pressure | | | | | |Thyroid | | | | | | |Blood Clots | | | | | |High Cholesterol | | | | | |Tuberculosis | | | | | | |Bunion | | | | | |Liver Disease | | | | | |Ulcers | | | | | | |MRSA (staph infec) | | | | | |Low Blood Pressure | | | | | |Varicose Veins | | | | | | |Auto immune Disorder | | | | | |Kidney Disease | | | | | |Currently Pregnant | | | | | | |LIST PAST SURGERIES ( I have had no surgeries.
___________________________________________________________________________________________
___________________________________________________________________________________________
SOCIAL HISTORY
Alcohol Use: ( Do not drink ( Less than 3/mo ( 1-2 drinks/wk ( 3-5 drinks/wk ( 5 or more/wk
Do you smoke or vape? ( No ( Yes If so, for how many years? _____ How much per day? ___________
List your current athletic activities (also indicate frequency) ____________________________________________
___________________________________________________________________________________________
SHOE SIZE _________________ HEIGHT ______________________ WEIGHT ________________________
PREFERRED PHARMACY:____________________________ ___________________________________ Pharmacy Name Location (Street, City)
I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet and/or ankles.
Patient/Parent Signature _______________________________________ Date __________________________
-----------------------
Northeast Wisconsin
Foot & Ankle Associates PATIENT HEALTH INFORMATION
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