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Kentucky Foot Professionals
Full Name:___________________________________________ Date:_______________
Person completing form if other than patient _____________________________________
Height:____________
Weight:____________
Past Medical History/Medical Problems
Please check all that apply:
|□ Anxiety |□ Diabetes/High Sugar |□ Joint Replacements (see below) |
|□ Arthritis (DJD, osteoarthritis) | Do you use insulin? □ yes □ no |□ Kidney Disease |
|□ Arthritis (Rhuematoid) |□ Emphysema/COPD |□ Liver Disease/Cirrhosis |
|□ Asthma |□ Gastric Bypass Surgery |□ Mental or Mood Disorder/Bipolar |
|□ Atrial Fibrillation (AFIB) |□ Glaucoma |□ Nerve Disorder/Problems |
|□ Back Pain/Disc Disease |□ Gout |□ Osteoporosis/Weak bones |
|□ Blood Clots/Pulmonary Embolism |□ Heart Attack |□ Seizure Disorder |
| Specify__________________________ |□ Heart Disease |□ Stomach Ulcer/Bleed/GERD |
|□ Cancer |□ Heart Surgery/Stents (see below) |□ Stroke/ CVA/ TIA |
| Specify__________________________ |□ Hepatitis B/C |□ Thyroid Disease |
|□ Crohn’s Disease/IBS |□ HIV |□Vision Problems/Glasses |
|□ Depression |□ High Blood Pressure |□ _______________________________ |
|□ Dialysis (Hemodialysis or peritoneal) |□ High Cholesterol/Lipids |□ _______________________________ |
| | |□ _______________________________ |
Social History
|Race: _________________________________________ |Do you live alone? □ Yes □ No |
|Ethnicity: ______________________________________ |Do you have home health services? □ Yes □ No |
|□ Single □ Married □ Divorced □ Widowed | If yes: ____________________________________________ |
|Do you smoke? Yes □ or No □ |Occupation: ___________________________________________ |
| If yes_______ # years, ______ packs per day |Illicit Drug Use? □ Yes □ No |
|Do you drink alcohol? Yes □ or No □ | If yes, type and frequency____________________________ |
| If yes _______ # drinks per week | |
|Do you live in a nursing home? Yes □ or No □ | |
Family History
Mother: □ Diabetes □ Heart disease □ Nerve disorder □ Arthritis □ Other__________________
Father: □ Diabetes □ Heart disease □ Nerve disorder □ Arthritis □ Other__________________
Siblings: □ Diabetes □ Heart disease □ Nerve disorder □ Arthritis □ Other__________________
Other Relative____________ □ Diabetes □ Heart disease □ Nerve disorder □ Arthritis □ Other ______________
Please list ALL SURGERIES and dates:___________________________________________________________________________
_____________________________________________________________________________________________________________
Medication ALLERGIES and reaction:____________________________________________________________________________
_____________________________________________________________________________________________________________
Other allergies (including food/latex):_______________________________________________________________________________
List ALL medications you are currently taking (including vitamins and supplements)
|Medication |Dose |Frequency |Medication |Dose |frequency |
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Recent Hospitalizations/Procedures:_______________________________________________________________________________
Pharmacy: ____________________________________________________________________________________________________
Kentucky Foot Professionals
2130 Nicholasville Road, Suite #1
Lexington, KY 40503
859-278-7313
Please fill in to the best of your ability. Thank You.
Full Name____________________________________________________Date:_______________
Chief Complaint/ Reason for visit today__________________________________________________________
__________________________________________________________________________________________
How long has condition been present? ___________________________________________________________
Did the condition start suddenly/gradually? _______________________________________________________
History of injury related to condition? ___________________________________________________________
Where in foot? _____________________________________________________________________________
Anything make it better? _____________________________________________________________________
Anything make it worse? _____________________________________________________________________
Rate pain by circling the appropriate number 10 9 8 7 6 5 4 3 2 1 0 (10 being worst pain imaginable)
Any previous treatments/medications?____________________________________________________________
Primary Care Physician and Date last seen:________________________________________________________
Do I need a test for PAD (Peripheral Artery Disease)? This condition affects over 8 million Americans and may have a significant impact on your medical care and outcome. Answer the next questions to help us determine if you are at risk for PAD and if vascular examination is necessary.
1. Do you have foot, calf, thigh, hip or buttock discomfort (aching, fatigue, tingling, cramping or pain) with walking that is relieved with rest? □ Yes □ No
2. Do you experience any pain AT REST in your lower legs or feet? □ Yes □ No
3. Do you experience toe or foot pain that disturbs your sleep? □ Yes □ No
4. Are your toes or feet pale, discolored, or bluish? □ Yes □ No
5. Do you have foot/leg skin wounds or ulcers that are slow to heal (8-12 weeks)? □ Yes □ No
6. Has your doctor told you that you have diminished/absent foot pulses? □ Yes □ No
7. Have you suffered a severe injury to the leg? □ Yes □ No
8. Do you have an infection of the feet or legs that may be gangrene (black skin/tissue)? □ Yes □ No
Please list any other pertinent information that would be helpful to the doctor.
Patient Signature:______________________________________________________
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