WILLIAMS FOOT CENTER
WILLIAMS FOOT CENTER, PLLC
Reason for your visit today __________________________________
List today’s pain level from 1 to 10:______________________________________
Primary Care/Family Doctor_________________________________ Phone _____________________
Referring Doctor (if applicable) ______________________________ Phone _____________________
Any recent lab work? When/where?______________________________________________________
Any recent Xray/MRI? When/where? _____________________________________________________
MEDICAL HISTORY
|Yes |No |Recent Illness/Describe: |Yes |No |Allergies |
|Yes |No |Eye Problems/Describe: |Yes |No |Depression/Describe: |
|Yes |No |Heart/Describe: |Yes |No |Anxiety/ Describe: |
|Yes |No |High Blood Pressure |Yes |No |Psychiatric Problems/Describe: |
|Yes |No |Peripheral Vascular Disease |Yes |No |COPD |
|Yes |No |Strokes |Yes |No |Asthma |
|Yes |No |Back Problems/Describe: |Yes |No |Pneumonia |
|Yes |No |Osteoporosis |Yes |No |Pleurisy |
|Yes |No |Skin Problems/Describe: |Yes |No |Stomach Problems |
|Yes |No |Cramps in feet/legs |Yes |No |Kidney Disease/Stones |
|Yes |No |Numbness in feet/legs |Yes |No |HIV |
|Yes |No |Neuropathy/Describe: |Yes |No |Hepatitis |
|Yes |No |Diabetes*: Type I_____ Type II______ |Yes |No |Cancer/Describe: |
|Yes |No |Do you take Insulin? |Yes |No |Falls within the past 12 months? How Many ___ |
|Yes |No |Liver Disease |Yes |No |Are you in pain management?** |
|Yes |No |Thyroid Disorder |Yes |No |Are you permanently disabled?*** |
*Name of physician who treats your diabetes (if applicable): _________________________________________
Last visit to diabetes doctor:__________________________
**Name of physician (or clinic) who treats your chronic pain: ________________________________________
Last visit to pain management: _______________________
***List the medical condition that led to your permanently disability status:____________________________
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