Sa1s3.patientpop.com



Centreville Foot & Ankle ClinicDr. James HurstPatient History FormsWho is your primary care doctor? ____________________________ Phone number __________________________When were you last seen by this doctor? ___________________________________If you are under the regular care of any other doctors, or see an endocrinologist or vascular surgeon, please list their names: ________________________________________________________________________________________ MEDICAL HISTORY (Check all that apply)AIDS/HIV___Diabetes___High Blood Pressure ___Stomach ulcers___Anemia___Epilepsy___High Cholesterol___Thyroid problems ___Arthritis___GERD___Kidney Disease___Tuberculosis___Asthma___Gout___Liver Disease___Valve/Joint replacement___Bleeding problem___Heart Disease___Phlebitis___Varicose veinsCancer___HepatitisCURRENT MEDICATIONS:___Stroke___Other ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________HAVE YOU EXPERIENCED…___________________________________________________________YESNOYESNOBack problems______Headaches______Burning, tingling or numbness in toes______Itchy skin on feet ______Dryness of skin______Reaction to local anesthetic______Episodes of Fainting ______Shortness of breath______Foot/leg cramps while sleeping ______Swelling of Feet/Ankles______Foot/Leg cramps while walking______Keloid or thick scars______ALLERGIES: List allergies below -OR- _____ Check if you have NO known drug allergiesPlease check all that apply:Adhesive Tape ____Local Anesthetics____ Sulfa Drugs____Aspirin ____Shellfish____Penicillin____Demerol ____Iodine ____Codeine____Latex____Other ___________________SURGICAL HISTORY (Procedure and year) __________________________________________________________ ______________________________________________________________________________________________Centreville Foot & Ankle ClinicDr. James M. Hurst D.P.MPatient History Cont. Patient Name_______________________________________________________SOCIAL HISTORY Do you smoke? YES NO Do you drink alcohol ? YES NO Do you drink coffee? YES NOFAMILY HISTORY Diabetes ____ Heart Disease ____ Cancer ____ Keloid scars ____ Sickle cell disease ____What is your chief foot/ankle/leg complaint today? ______________________________________________________How long has it been bothering you? _________________If applicable, what was the date of injury? ______________Previous treatments? _______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download