WILLIAMS FOOT CENTER
WILLIAMS FOOT CENTER, PLLC Chart # ________
SURGICAL HISTORY
Please list ALL surgeries with dates:
________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
FAMILY HISTORY
List any significant illnesses that run in your immediate family (parents, siblings, children):
________________________________________________________________________________________________________________________________________________________________________________________
SOCIAL HISTORY
Do you use tobacco products? Yes_____ No_____ Product: _____________________
Do you smoke? Current smoker_____ Former smoker_____ Never smoked_____
Do you drink alcohol? Yes _____ No _____
Do you use illegal/street drugs? Yes _____ No _____
Have you had your flu shot? Yes_____ No_____ When?__________
Have you had your Pneumonia shot? Yes_____ No_____ When?_________
Weight: _________ Height: ___’ ___” Shoe Size:__________________
DIABETIC HISTORY
A1C level: ______ Blood Sugar today: ________AM/PM Date Last Seen Doctor: _________
MEDICATION HISTORY
List ALL medications you currently take:
Name Dosage How Often # per day Used for
________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
____________________________________________________________________________________________
_____See attached list of medications (if applicable)
ALLERGIES
List ALL known allergies to medications (M), foods (F) and environment (E): (describe symptoms)
________________________________________________________________________________________________________________________________________________________________________________________
PHARMACY
Name___________________________________________ Phone __________________________________
Street___________________________________________ City____________________________________
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