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Health History Form

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

Preferred Method of Contact
Marital Status

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

Podiatry Information

Are you having pain?
If yes, please specify when
Describe your pain
Is this due to an injury?
Is this work related?
Any previous treatment?
Past Surgical History
Type of shoes you wear most often?
Your job is mostly

Medical Information

Are you currently under the care of a physician?
Has there been any change in your general health within the past year?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Do you take any blood thinners?
Medical History: Are you presently being treated for any medical conditions?

Pharmacy Information


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

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.

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.