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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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