• PATIENT MEDICAL INFORMATION

    To help us meet your health care needs, please complete the following questionnaire.
  • Date of Birth*
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    2 digit month, 2 digit day, 4 digit year

  • WHAT BRINGS YOU IN TO SEE US TODAY?

  • Was there an accident or injury?*

  • PAST MEDICAL HISTORY

  • Have you ever HAD or HAVE any of the following:

  • Past SURGERIES with date:

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    2 digit month, 2 digit day, 4 digit year
  •  / /
    2 digit month, 2 digit day, 4 digit year
  •  / /
    2 digit month, 2 digit day, 4 digit year
  •  / /
    2 digit month, 2 digit day, 4 digit year

  • Past HOSPITALIZATIONS with date:

  •  / /
    2 digit month, 2 digit day, 4 digit year
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    2 digit month, 2 digit day, 4 digit year
  •  / /
    2 digit month, 2 digit day, 4 digit year
  •  / /
    2 digit month, 2 digit day, 4 digit year

  • SOCIAL HISTORY

  • Marital Status
  • Work Status
  • Smoker?
  • Former, quit date:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Vaping?
  • Former, quit date:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Alcohol Use?
  • Yes, how often?
  • Drug Use?
  • Former, quit date:
     / /
    2 digit month, 2 digit day, 4 digit year
  • Currently, what type?
  • Have you gotten a flu vaccine this season? (October - May)
  • Date:*
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    2 digit month, 2 digit day, 4 digit year
  • Have you gotten a pneumonia vaccine within the last 5 years?
  • Date:*
     / /
    2 digit month, 2 digit day, 4 digit year
  • Have you experienced 2 falls OR any falls with injury in the last year?
  • Were you injured by the fall or did it limit your activities for at least one day?
  • Did you see a doctor due to the fall?

  • REVIEW OF SYMPTOMS: Are you CURRENTLY experiencing any of the following:

  • GENERAL:
  • EARS / NOSE / THROAT / MOUTH:
  • CARDIOVASCULAR:
  • RESPIRATORY:
  • GI:
  • GU:
  • MUSCULO:
  • SKIN:
  • NEUROLOGIC:
  • PSYCHIATRIC:
  • ENDOCRINE:
  • HEMA / LYMPH:

  • FAMILY HISTORY: Has any member of your immediate family been treated for the following?

  • Arthritis
  • High Blood Pressure
  • Cancer
  • Heart Disease
  • Diabetes Type-1
  • Diabetes Type-2
  • UNKNOWN

  • ALLERGIES: Please CHECK any of the following to which you've had ALLERGIC REACTIONS to:

  • MEDICATIONS: Are you currently taking any medications?

  • I hereby give permission to the physician(s) at Complete Foot and Ankle Specialists, LLC to examine, photograph, administer treatment and perform such minor operative procedures as may be deemed necessary in the diagnosis and/or treatment of my feet and/or ankles.

  • Current Date
     / /
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: