Medical history information

WSFAC Registration & Medical Questionnaire This information is important for our records and your health
Patient Name: _________________________________________

Primary Care Physician: __________________________ Phone # (___) ____-_________
May we contact your physician about your health?

Referring Physician: _________________________________________________________
Describe your current problem/complaint:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
How often does it bother you? _______________________________________________
Where on your foot does it bother you? _______________________________________
When does it bother you the most? ___________________________________________
How long does the pain last? ________________________________________________
What are your symptoms? __________________________________________________
What are the relieving factors? ______________________________________________
What aggravates it? _______________________________________________________
Pharmacy: _________________________ Phone#:_____________________________
MEDICATIONS

What medications are you currently taking? Please list all.

Name: _______________________________ Dosage: ___________________________
Name: _______________________________ Dosage: ___________________________
Name: _______________________________ Dosage: ___________________________
Name: _______________________________ Dosage: ___________________________
Patient Name: _____________________________
ALLERGIES
Name: _______________________________ Reaction: __________________________________ Severity: ___Extreme___ Moderate ___ Mild Name: _______________________________ Reaction: __________________________________ Severity: ___Extreme___ Moderate ___ Mild Do you have problems taking Aspirin/Motrin?

Any problems with local anesthetics? (Novocaine, Lidocaine)? Yes: _____ No: ______
Pharmacy: _______________________________ Phone #: _____________________________

PAST MEDICAL/SURGICAL HISTORY
Any past medical problems on your feet and ankles? Please explain:
_________________________________________________________________________________
_________________________________________________________________________________
Any past surgical procedures on your feet and ankles? Please explain:
_________________________________________________________________________________
_________________________________________________________________________________
Have you had any serious illnesses? Please explain:

_________________________________________________________________________________
_________________________________________________________________________________
Please list any previous surgeries including date and physicians name:
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
Check any of the following that you have, or have had a problem with:
____ Cardiovascular
____ Musculoskeletal ____ Integumentary (skin) Patient Name: ___________________________________
Do you have Diabetes? ___ Yes ___ No
If yes, do you take insulin? ___ Yes ___ No _____
Number of years? __________

Do you have any artificial joints?
Other: _____________________________________________________________________
Do you have a Heart Valve Implant? ___ Yes ___ No
Do you have a Pacemaker?

Height: ____________________
Weight: ______________________
Shoe size: _______
SOCIAL HISTORY
Do you smoke? ___ Yes ___No # of packs per day? ___ Previously smoked? ___ Yes ___ No

Do you drink alcohol? ___ Yes ___ No _____Light usage (1-2 per week) ___ Moderate (1-2 per day) ___Heavy ( > 2 per day )
Occupation: _____________________ Hobbies: ________________ Exercise: _________________
FAMILY HISTORY
CONDITION
RELATIONSHIP TO PATIENT

Source: http://www.wsfac.net/New_Patient_Health_History.pdf