Medical History

This secure form consists of 3 parts and will take approximately 5 minutes to complete. Information on this page is protected with up to 256-bit encryption. We do NOT require your Social Security Number.

1. Patient Information
First Name:  
Last Name:  
Email:
Address:  
City:  
State:  
Zip Code:  
Date of Birth:  
Home Phone:  
Marital Status:
Sex:
Employer / School:
Employer / School Phone:
In case of emergency contact Name & address:
2. Insurance
Who is the primary on this account:
Date of birth of the primary:
Relationship to patient:
Insurance Company:
Group Number:
Subscriber ID:
Insurance Phone Number:
Is patient covered by other insurance:
3. Podiatric and Medical History
Main reason for visiting us: e.g. foot, ankle, knee...
Have you been to a Podiatrist(s) before:
Cigarette / Tobacco use:
Is there any personal or family history of diabetes:
Please indicate which foot problems you now have or have had in the past:
Ankle Pain: Flat Feet:
Athlete's Foot: Foot or Leg Cramps:
Bunions: Heel Pain:
Corns & Calluses: Ingrown Toenails:
Cramps or Numbness in Feet or Legs: Plantar Warts:
Please choose "YES" or "NO" to indicate if you have had any of the followings:
AIDS/HIV: Hepatitis or Jaundice:
Allergies to Anesthetics: High Blood Pressure:
Allergies to Medicine or Drugs: Kidney Problems:
Anemia: Liver Disease:
Angina: Low Blood Pressure:
Arthritis: Neuropathy:
Artificial Heart Valves or Joints: Phlebitis:
Asthma: Psychiatric Care:
Back Problems: Radiation Treatment:
Bleeding Disorders: Rash:
Cancer: Respiratory Disease:
Chemical Dependency: Rheumatic Fever:
Chest Pain: Shortness of Breath:
Chronic Diarrhea: Sinus Problems:
Circulatory Problems: Special Diet:
Diabetes: Stroke:
Ear Problems: Swelling in Ankles, Feet:
Epilepsy: Swollen Neck Glands:
Eye Problems: Tired Feet:
Fainting: Tuberculosis:
Gout: Ulcers:
Headaches: Varicose Veins:
Heart Disease: Venereal Disease:
Hemophilia: Weight Loss, Unexplained:
Surgeries you have had:
Hospitalization other than for the surgeries listed:
Family physician Name & last date visited:
Are you now, or have you been, under any other doctor's care for any reason over the past two years?
Medications? Include prescriptions, over-the-counter medications and vitamins:
Pharmacy Name(s):
Pharmacy Phone(s):
Do you take oral contraceptives:
Allergies
Adhesive/Tape: Local Anesthetics:
Anticoagulant Therapy: Novocaine:
Aspirin: Penicillin:
Codeine: Seafoods:
Demerol: Sulfa:
Iodine:    
Other:
Treatment Consent
I hereby consent and give my permission to the doctor (and the doctor's assistants or designated replacement) to administer and perform such procedures upon me as the doctor seems necessary.
The information contained above is intended for general reference purposes only. It is not a substitute for professional medical advice or a medical exam. Always seek the advice of your physician or other qualified health professional before starting any new treatment. Health information on this website MUST NOT be used to diagnose, treat, cure or prevent any disease without the supervision of your doctor.