[PRACTICE NAME]



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?

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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:

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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:

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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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