Health History Form

Email Address

Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

First Name

Last Name

Middle Initial

Home Phone

Cell Phone

Work Phone

Preferred Method of Contact

Phone

Text

Mailing Address

City

State

Zip

Date of Birth

Sex

Male

Female

Marital Status

Occupation

Emergency Contact Name

Emergency Contact Number

How did you hear about us?

If you are completing this form for another person, what is your relationship to that person?

Your Name

Relationship

Home Phone

Cell Phone

Podiatry Information

What is your foot/ankle problem(s)?

Where is the location of your problem(s)? (Right/Left/Both)

How did this problem start?

When did this problem start?

Are you having pain?

Yes

If yes, please specify when

In shoes

Standing

Walking

Running/Exercise

Resting

Describe your pain

Sharp

Dull

Aching

Tingling

Burning

Other

If other, please specify

Is this due to an injury?

Yes

Is this work related?

Yes

Any previous treatment?

Yes

If yes, please specify date

By whom?

What was the treatment?

Previous foot/ankle surgery or injuries?

Past Surgical History

None

Type of shoes you wear most often?

Work Boots

Steel Toe Shoes

Sneakers

Flats

Dress

Pumps

Nurses Shoes

Sandals

Running

Other

If other, please specify

Your job is mostly

Sitting

Standing

Walking

Lifting

Carrying

Climbing

Using Machinery

Driving

Other

If other, please specify

Medical Information

Are you currently under the care of a physician?

Yes

Physician Name

Phone Number

Has there been any change in your general health within the past year?

Yes

If yes, what condition is being treated?

Date of last physical exam

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes

If yes, what was the illness or problem?

Do you take any blood thinners?

Yes

Medications

None

Please list all medications, including vitamins, natural or herbal preparations and/or diet supplements you take

Please list what you are allergic to (or have had a reaction to).

No known drug allergies

Medical History: Are you presently being treated for any medical conditions?

Diabetes

High blood pressure

Kidney problems

Heart disease

Back problems

Ulcers

Gout

Vascular disease

Other

No pertinent medical history

If other, please list what diseases or problems you have (or have had).

Pharmacy Information

Pharmacy Name

Pharmacy Phone

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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