[PRACTICE NAME] - Foot & Ankle Care of Boulder County
Medical History
Patient Name: [pic] Date of Birth: [pic]
Medications/Supplements
Please list all medications you are currently taking
(Include prescriptions, over-the-counter meds and herbal supplements):
Name Dose How often do you take?
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Please list all prior surgeries and Significant Hospitalizations:
Type of Surgery Date Type of Surgery Date
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Primary Care Doctor: [pic] Phone #: [pic]
Pharmacy: [pic]
Location: [pic] Phone #: [pic]
Social & Family History
Patient Name: [pic] Date of Birth: [pic]
Marital Status:
[pic] [pic] [pic][pic][pic] [pic]
Use of Alcohol:
[pic][pic][pic][pic]
If Current: Type [pic] [pic] [pic] [pic][pic]
Use of Tobacco:
[pic][pic][pic][pic]
If Quit, how long ago? [pic] If Smoke: [pic] packs/day for [pic]years
Use of Recreational Drugs:
[pic][pic][pic]
If Quit: how long ago? Years [pic] Type [pic]
If Current: Type [pic] [pic] [pic] [pic][pic]
Employer: [pic] Occupation: [pic]
How much are you on your feet at work?
[pic] [pic][pic][pic][pic]
Do others depend upon you for their care?
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Exercise
[pic] [pic] [pic][pic][pic]
Types of exercise: [pic]
Do you have a family history of: [pic][pic][pic][pic][pic][pic][pic][pic][pic] [pic]
Patient Name: [pic] Date of Birth: [pic]
Allergies:
[pic] [pic]
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Have you ever had any of the following?
|Acid Reflux |[pic][pic] | |Fibromyalgia |[pic][pic] | |Neuropathy |[pic][pic] |
|Anemia |[pic][pic] | |Gout |[pic][pic] | |Open Sores |[pic][pic] |
|Arthritis |[pic][pic] | |Heart Attack |[pic][pic] | |Pneumonia |[pic][pic] |
|Asthma |[pic][pic] | |Heart Disease/Failure |[pic][pic] | |Polio |[pic][pic] |
|Back Trouble |[pic][pic] | |Hepatitis |[pic][pic] | |Rheumatic Fever |[pic][pic] |
|Bladder Infections |[pic][pic] | |HIV+/AIDS |[pic][pic] | |Sickle Cell Disease |[pic][pic] |
|Abnormal Bleeding |[pic][pic] | |High Blood Pressure |[pic][pic] | |Skin Disorder |[pic][pic] |
|Blood Clots |[pic][pic] | |Kidney Disease |[pic][pic] | |Sleep Apnea |[pic][pic] |
|Blood Transfusion |[pic][pic] | |Liver Disease |[pic][pic] | |Stomach Ulcers |[pic][pic] |
|Bronchitis/Emphysema |[pic][pic] | |Low Blood Pressure |[pic][pic] | |Stroke |[pic][pic] |
|Cancer |[pic][pic] | |Migraine Headaches |[pic][pic] | |Thyroid Disease |[pic][pic] |
|Diabetes: [pic][pic] |[pic][pic] | |Mitral Valve Prolapse |[pic][pic] | |Tuberculosis |[pic][pic] |
Other Conditions:
[pic]
to the best of your knowledge, are you pregnant (or do you think you could be?)
[pic][pic][pic]
Current Problem
Patient Name: [pic] Date of Birth: [pic]
What specific problem brings you to our office today? [pic]
Where is the pain/problem located? Please mark on the pictures below.
Left Foot Right foot
How long ago did his problem first start? [pic] days/weeks/months/years
Did your pain or problem:
[pic] [pic]
How would you describe your pain?
[pic][pic][pic][pic][pic] [pic][pic][pic]
[pic][pic]
How would you rate your pain on a scale from 0 to 10?
(no pain) [pic] [pic] [pic][pic] [pic][pic] [pic][pic] [pic] [pic][pic] (worst pain possible)
Since the time your pain or problem began, has it:
[pic] [pic][pic]
Current Problem – Cont.
Patient Name: [pic] Date of Birth: [pic]
What makes your pain or problem feel worse? [pic] [pic] [pic] [pic][pic][pic][pic][pic][pic]
[pic][pic]
What makes your pain or problem feel better? [pic]
What treatments have you had for this problem? [pic]
How has this problem affected your lifestyle or ability to work? [pic]
Was this problem caused by an injury? [pic] [pic] [pic]
If yes, was it a work-related injury? [pic][pic]
To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account for any professional services rendered. I hereby acknowledge and agree that if my account becomes delinquent it will be subject to collection service. I agree to pay all court costs and reasonable attorney fees for collection of all past due amounts owed, plus interest on all such amounts outstanding. I understand and agree that my signature below confirms that I am authorizing foot and ankle care of boulder county and their billing service to call me on my mobile phone, if provided, for any reason to include collecting any balances due. I certify that the information provided is correct to the best of my knowledge. I authorize the release of any pertinent information regarding my medical care, and assignment of benefits from my insurance company to my physician.
[pic] ___________________________________________________
Print name of patient, parent or guardian Signature
[pic] [pic]
If other than patient, relationship to patient Date
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Top of Foot
Bottom of Foot
Bottom of Foot
Top of Foot
Inside of foot
Outside of Foot
Outside of Foot
Inside of foot
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