Soffer Foot and Ankle Care
Soffer Foot and Ankle Care, L.L.C.
NEW PATIENT HISTORY FORM
Date:__________ Patient name:_____________________________________________ Age: _______ DOB: __________
|PODIATRIC HISTORY: Please indicate your foot problems and diagnoses: |
|(Yes (No |Fungal toenails |
|(Yes (No |Athlete’s foot |
|(Yes (No |Ingrown toenails |
|(Yes (No |Corns and calluses |
|(Yes (No |Numbness or tingling in feet or legs |
|(Yes (No |Foot or leg cramps |
|(Yes (No |Heel pain (plantar fasciitis) |
|(Yes (No |Ankle pain |
|(Yes (No |Foot or ankle swelling |
|(Yes (No |Plantar warts |
|(Yes (No |Chronic wound |
|(Yes (No |Bunion |
|(Yes (No |Neuroma |
|(Yes (No |Hammertoe |
|(Yes (No |Flat feet |
|(Yes (No |Diabetic foot |
|(Yes (No |Gout |
|(Yes (No |Other: |
|Please indicate if you have any of these symptoms: |
|(Yes (No |Fevers |
|(Yes (No |Chills |
|(Yes (No |Nausea/Vomiting |
|(Yes (No |Leg discoloration |
|(Yes (No |Chest Pain |
|(Yes (No |Shortness of Breath |
|(Yes (No |Leg swelling |
|(Yes (No |Leg pain |
Reason for your visit: _____________________________ _______________________________________________
_______________________________________________
_______________________________________________
_______________________________________________
Preferred phone number to call with test results: _______________________________________________
Ok to leave a message? _____________________
Do you currently smoke or use tobacco products? _____
If so, how many packs per day? _______________
For how many years? _______________________
Have you quit smoking? ___________________________
When did you quit? ________________________
How many packs/day did you to smoke? _______
For how many years? _______________________
Do you drink alcohol? _____________________________
If so, how many drinks per week? _____________
Do you use heroin, cocaine, methamphetamines, or other recreational drugs? _________________________
Occupation? ____________________________________
Do you exercise? _________________________________
If so, how many times per week? _____________
How many minutes each time? ______________
What kind of exercises? ____________________
Do you live alone? _______________________________
If not, who lives with you? __________________
|Have you ever seen any of the following specialists? If so, please list name, date seen, and treatment: |
| |Specialist: |Name: |Date last seen: |Treatment recommended: |
|(Yes (No |Primary care physician | | | |
|(Yes (No |Podiatrist | | | |
|(Yes (No |Vascular surgeon | | | |
|(Yes (No |Infectious disease | | | |
|(Yes (No |Endocrine (diabetes) | | | |
|(Yes (No |Neurologist | | | |
|Please check if you have had the following treatments for your feet before: |
|Treatment: |Start Date: |Duration: |Type/Comment: |
|( Antibiotics | | | |
|( Topical care | | | |
|( Hospitalization | | | |
|( Surgery | | | |
|( X-rays | | | |
|( MRI | | | |
|( Other: | | | |
|SURGICAL HISTORY: |
|Disease/Diagnosis/Injury |Procedure or surgery |Date |Physician |Hospital |
| | | | | |
| | | | | |
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| | | | | |
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|MEDICAL HISTORY: Please indicate if you have been diagnosed with any of the |
|conditions listed |
|(Yes (No |Diabetes Type I |
|(Yes (No |Diabetes Type II |
|(Yes (No |Peripheral artery disease (poor circulation) |
|(Yes (No |Venous disease |
|(Yes (No |Peripheral neuropathy (poor sensation) |
|(Yes (No |Blood clots |
|(Yes (No |Kidney disease |
|(Yes (No |Stomach or intestinal problems |
|(Yes (No |Asthma or COPD |
|(Yes (No |Heart disease |
|(Yes (No |High blood pressure |
|(Yes (No |High cholesterol |
|Other: | |
|ALLERGIES: |
|( None |
|( Adhesive/ Tape |
|( Ibuprofen |
|( Penicillin |
|( Sulfa drugs |
|( Latex |
|( Iodine |
|( Other: |
|Please indicate any family members (parent, sibling, grandparent, or child) with the following conditions: |
| |Condition |Relationship to you: |Age at diagnosis: |
|(Yes (No |Diabetes | | |
|(Yes (No |Blood clots | | |
|(Yes (No |Stroke | | |
|(Yes (No |Heart Attack | | |
|MEDICATIONS: (If you have a list, please attach) |
|NAME |DOSE |ROUTE |FREQUENCY |REASON |
| | | | | |
| | | | | |
| | | | | |
| | | | | |
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| | | | | |
To be filled out by medical staff:
BP_______________ Pulse __________________ Temp_________________ Weight _________________ Height______
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