COLLIER PODIATRY, P.A.

COLLIER PODIATRY, P.A.

WELCOME TO OUR OFFICE

Please complete the following: (Please Print)

Today's Date

_

Last Name:

First Name:

Marital Status:

S

M

D

W Name of Spouse:

Race: (Circle Caucasian

One)

African American

Asian

Hispanic/ Latino

Other:

Height: Home Phone:

Weight:

State of Primary Residence

Shoe Size: Work:

E-Mail Address:

M:

Date of Birth:

Ethnicity:

(Circle One)

Hispanic/ Latino

NOT Hispanic / Latino

Gender:

(Circle One)

Female

Male

Mobile:

Local Address: City:

State:

Zip:

Second or Out-of-State Address: City:

State:

Zip:

Pharmacy:

Pharmacy Phone:

Pharmacy Address or Intersection:

Retired:

Employed:

Employer:

Employer Phone:

Name of Emergency Contact: Emergency Contact Phone Number:

Relationship:

Name of Primary Care Physician:

Phone:

Fax:

Date Last Seen: Address:

Page 1 of 7

COLLIER PODIATRY, P.A.

REVIEW OF SYSTEMS:

Please circle Yes or NO for each item

General Symptoms:

Chills

Yes No

Weakness

Yes No

Fatigue

Yes No

Weight Gain

Yes No

Fever

Yes No

Weight Loss

Yes No

Dizziness Pain Fainting Sweats Headaches

Head:

Yes No Yes No Yes No Yes No Yes No

Bleeding Obstruction Discharge Infection

Nose:

Yes No Yes No Yes No Yes No

Bleeding Post Nasal Drip Dentures Dry Mouth

Mouth:

Yes No Yes No Yes No Yes No

Hearing Aid Infections Ringing

Ears:

Yes No Yes No Yes No

Gastrointestinal:

Antacid Use

Yes No

Excessive Thirst

Yes No

Hemorrhoids

Yes No

Throat/Neck:

Hoarseness

Yes No

Tenderness

Yes No

Lumps

Yes No

Sore Throat

Yes No

Respiratory:

Asthma

Yes No

Cough

Yes No

Tuberculosis/ T.B.

Yes No

Bronchitis

Yes No

Pleurisy

Yes No

Wheezing

Yes No

C.O.P.D.

Yes No

Short of Breath

Yes No

Cardiovascular:

Chest Pain

Yes No

Hair Loss on Legs

Yes No

History of MI

Yes No

Replacement Heart Valve Yes No

Vascular Grafts

Yes No

Cramps in Legs/Feet

Yes No

Heart Murmur

Yes No

Leg or Foot Ulcers

Yes No

Rheumatic Fever

Yes No

Extremity(s) Cool

Yes No

High Blood Pressure

Yes No

Palpations

Yes No

Varicose Veins

Yes No

Musculoskeletal:

Ankle Sprain

Yes No

Back Problems

Yes No

Bunions

Yes No

Corns

Yes No

Page 2 of 7

COLLIER PODIATRY, P.A.

Gastrointestinal continued:

Jaundice

Yes No

Nausea

Yes No

Constipation

Yes No

Gall Bladder Disease

Yes No

Hepatitis

Yes No

Laxatives

Yes No

Rectal Bleeding

Yes No

Diarrhea

Yes No

Heart Burn

Yes No

Hiatal Hernia

Yes No

Liver Disease

Yes No

Swallowing Problem

Yes No

Psychiatric:

Depression

Yes No

Disorientation

Yes No

Memory Loss

Yes No

Integumentary (Skin):

Athlete's Foot

Yes No

Fungal Nails

Yes No

Itching

Yes No

Mole Changes

Yes No

Dryness

Yes No

Hives

Yes No

Keloid Scar

Yes No

Rash

Yes No

Eczema

Yes No

Ingrown Nails

Yes No

Lumps

Yes No

Warts

Yes No

Swallowing Problem

Yes No

Neurological:

Black Outs

Yes No

Fainting

Yes No

Speech Disorders

Yes No

Tremors

Yes No

Burning

Yes No

Musculoskeletal continued:

Gout

Yes No

High Arch Feet

Yes No

Joint Pain

Yes No

Lower Back Pain

Yes No

Neuroma

Yes No

Restricted Motion

Yes No

Weakness

Yes No

Arch Pain

Yes No

Broken Ankle

Yes No

Calluses

Yes No

Flat Feet

Yes No

Hammer/Mallet Toes

Yes No

In-Toeing

Yes No

Joint Stiffness

Yes No

Muscle Cramps

Yes No

Orthotic Use

Yes No

Shoe Insert Use

Yes No

Arthritis

Yes No

Broken Foot Bone

Yes No

Childhood Foot Problems Yes No

Gait (Walking) Problems

Yes No

Heel Pain

Yes No

Joint Implants

Yes No

Knee Pain

Yes No

Muscle Stiffness

Yes No

Paralysis

Yes No

Toe Walking

Yes No

Endocrine:

Fatigue

Yes No

Thirst

Yes No

Weight Loss

Yes No

Goiter

Yes No

Thyroid

Yes No

Sweats

Yes No

Weight Gain

Yes No

Diabetic

Yes No

Most Recent A1C & Date Yes No

Page 3 of 7

COLLIER PODIATRY, P.A.

Neurological continued:

Neuromas

Yes No

Strokes

Yes No

Unsteady Gait

Yes No

Charcot Neuroarthropathy

Yes No

Numbness

Yes No

Tingling

Yes No

Neuropathy

Yes No

Allergic/Immunologic:

Hives

Yes No

Runny Nose

Yes No

Swelling

Yes No

Itchy Eyes

Yes No

Sneezing

Yes No

Watery Eyes

Yes No

Itchy Nose

Yes No

Stuffy Nose

Yes No

Wheezing

Yes No

Drug Allergies: Please List Below

Please Check if List Attached Please Check if NONE

Hematological / Lymphatic:

Anemia

Yes No

Easily Bruised

Yes No

Swollen Glands

Yes No

Bleeding Easily

Yes No

Recent Chemotherapy

Yes No

Transfusion Reaction

Yes No

Blood Clots

Yes No

Slow Healing Cuts

Yes No

Eye:

Blurred Vision

Yes No

Eye Glasses

Yes No

Cataracts

Yes No

Glaucoma

Yes No

Contacts

Yes No

Infections

Yes No

Medications: Please List Below

Please Check if List Attached Please Check if NONE

Pneumonia Other:

Immunizations: Please Provide Most Recent Date of the Following:

Date:

Influenza/ Flu

Date:

Date:

Other:

Date:

Medical History:

Please circle YES or NO have ever been treated for any of the following:

Anemia

Yes No

Arthritis

Yes No

Back Problem

Yes No

COPD

Yes No

High Cholesterol

Yes No

Depression

Yes No

Diabetes

Yes No

GERD

Yes No

Page 4 of 7

COLLIER PODIATRY, P.A.

Gout Hepatitis Irregular Heart Beat Osteoporosis Renal Stone Tuberculosis/ T.B. Anxiety Breast Cancer Dementia Epilepsy HIV Hip Pain Leg Cramps Pneumonia Restless Leg Syndrome Thyroid Disease

Medical History continued:

Yes No

Headache

Yes No

Hypertension

Yes No Yes No

MVP- Mitral Valve PPrroolsataptseeDisease

Yes No

Skin Cancer

Yes No

Ulcer (GI)

Yes No

Asthma

Yes No

Cancer

Yes No

Dermatitis

Yes No

Glaucoma

Yes No

Heel Pain

Yes No

Hysterectomy

Yes No

Migraine

Yes No

Psoriasis

Yes No

Stroke

Yes No

Other:

Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No

Surgeries:

Please check box if applicable

AAA Repair

Aortic Aneurysm

Appendectomy

Breast Augmentation

Breast Reduction

CABG

Carotid Endarterectomy

Cataract Extraction

Cesarean Section

Cholecystectomy

Colectomy

Duodenal Ulcer

ESWL

Ectopic Pregnancy

Fracture

Gall Bladder

Gastric Banding

Heart Valve

Abdominal Hernia

Hip Fracture

Hip Surgery

Hysterectomy

Intestinal By-Pass

Knee Arthroscopy

Knee Surgery Oophorectomy

(Ovary Removal)

Prior Surgeries

LS Spine Surgery PTCA

Prostate Biopsy

Lasik PVD Procedure Prostatectomy Retro

Mastectomy Pacemaker

Arthroscopy

Shoulder Surgery

Sinusectomy (Nasal)

Splenectomy

TURP

Thyroidectomy

Tonsillectomy

Tubal Ligation

Vasectomy

Other:

Page 5 of 7

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