Brian Crispell D.P.M
Brian Crispell D.P.M LLCNAME: ___________________________________________________________ DATE: ____________________DATE OF BIRTH: _________________REFERRED BY(DOCTOR/FRIEND)___________________________HEIGHT: _____________________ WEIGHT:___________________ SHOE SIZE: ______________________REASON FOR VISIT( PLEASE SPECIFY IF JOB RELATED OR ACCIDENT):____________________________________________________________________________________________________________________PERSONAL MEDICAL HISTORY: (CIRCLE ALL THAT APPLY)High Blood Pressure Heart Disease High Cholesterol ArthritisBleeding Problems Stomach Problems Nervous Problems/ Depression StrokeThyroid Disease Lung Problems Kidney Problems GoutCancer Hepatitis/Liver Problems Rheumatoid ArthritisHIVDiabetes: Insulin _____________ Pills _____________ Other MEDICAL PROBLEMS: __________________________________________________________________________________________________________RECENT SYMPTOMS (Circle all that apply) Weight change - Head injury - Headaches - Dizziness - Neck stiffness - Neck mass or lump - Shortness of breath - Cough - Coughing blood - Wheezing - Chest pain - Heart palpitations - Fainting - Dizziness upon Standing - Change in appetite - Problems eating - Belly pain - Change in bowel habits - Vomiting - Weakness - Tremors - Seizure - Pain in joints - Numbness - Problems walkingMEDICATIONS: __________________________________________________________________________________________________________________________________________________________________________MEDICATION ALLERGIES: __________________________________________________________________PAST-SURGICAL HISTORY: _______________________________________________________________________________________________________________________________________________________________SOCIAL HISTORY -SMOKING (Circle one) - YES NO FORMER NUMBER OF YEARS___________FAMILY HISTORY: CIRCLE ALL THAT APPLY- (write in family member affected BELOW disorder)Diabetes High Blood Pressure Heart Disease Cancer High CholesterolBleeding Problems Thyroid Problems Stroke Gout Asthma/Lung ProblemsPRIMARY DOCTOR NAME + ADDRESS + PHONE + LAST VISIT DATE: _____________________________________________________________________________________________ ................
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