New Patient Past Medical History (Updated 4/18/24)

PATIENT MEDICAL INFORMATION

To help us meet your health care needs, please complete the following questionnaire.
Patient Name*
Date of Birth*

MonthDayYear
Height*
Weight*
Shoe Size
Men'sWomen's
WHAT BRINGS YOU IN TO SEE US TODAY?
Please describe your foot / ankle problem:*
When did this begin?*
Was there an accident or injury?*

NOYES
Please describe:*
PAST MEDICAL HISTORY
Have you ever HAD or HAVE any of the following:

ArthritisBack ProblemsCancerColitisDepressionDermatitisPeptic UlcerAsthmaBleeding DisorderHeart DiseaseKidney DiseaseLung DiseaseHIV+High CholesterolHepatitisVenous DiseaseArtificial Valves or JointsGoutHigh Blood PressureRheumatoid ArthritisOsteoarthritisCirculatory ProblemsPneumoniaThyroid DiseaseTuberculosisDiabetes-Type 1Diabetes-Type 2Gallbladder ProblemsNeuropathyAny other medical problems not listed above
NONE OF THE ABOVE
Past SURGERIES with date:
Surgery Description
MonthDayYear
Surgery Date
Surgery Description
MonthDayYear
Surgery Date
Surgery Description
MonthDayYear
Surgery Date
Surgery Description
MonthDayYear
Surgery Date
Past HOSPITALIZATIONS with date:
Hospitalization Description
MonthDayYear
Hospitalization Date
Hospitalization Description
MonthDayYear
Hospitalization Date
Hospitalization Description
MonthDayYear
Hospitalization Date
Hospitalization Description
MonthDayYear
Hospitalization Date
SOCIAL HISTORY
Marital Status

SingleMarriedDivorcedWidowedSeparated
Occupation
Work Status

Employed, Full-timeEmployed, Part-timeRetiredDisabledUnemployed
Smoker?

NeverFormerCurrently
Former, quit date:

MonthDayYear
Currently, how long?
Light Smoker (10 or fewer / day)Heavy Smoker (More than 10 / day)
Vaping?

NeverFormerCurrently
Former, quit date:

MonthDayYear
Currently, how long?
How many times a day?
Alcohol Use?

NeverYes
Yes, how often?

WeeklyOccasionallyRarely
Drug Use?

NeverFormerCurrently
Former, quit date:

MonthDayYear
Currently, what type?

MarijuanaIllegalOther
Illegal, what type?
Have you gotten a flu vaccine this season? (October - May)

NoYes
Date:*

MonthDayYear
Have you gotten a pneumonia vaccine within the last 5 years?

NoYes
Date:*

MonthDayYear
Have you experienced 2 falls OR any falls with injury in the last year?

NoYes
Were you injured by the fall or did it limit your activities for at least one day?

NoYes
Did you see a doctor due to the fall?

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

ChillsFeverUnexplained weight gainUnexplained weight loss
EYES:

Eye symptoms
EARS / NOSE / THROAT / MOUTH:

Ear SymptomsNasal symptomsThroat / mouth symptoms
CARDIOVASCULAR:

Chest painCold feetNumbness / tingling in feetRest painPain in calf's when walkingStiffness in jointsSwelling of legsSwelling of feetSwelling of anklesNon-healing ulcerVein problems
RESPIRATORY:

Shortness of breathCoughCongestion
GI:

Changes in appetiteConstipationDiarrheaIndigestionNauseaUlcersVomiting
GU:

Urinary frequencyExcessive urinationPain with urination
MUSCULO:

History of fallsLeg crampsMuscle achesTenderness
SKIN:

Skin symptomsHair symptomsNail symptoms
NEUROLOGIC:

Difficulty with balanceHeadacheLightheadednessRestless leg syndromeStroke
PSYCHIATRIC:

AnxietyInsomniaMemory lossMood changes
ENDOCRINE:

Dry skinHair lossExcessive sweatingExcessive thirstThyroid problems
HEMA / LYMPH:

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

MotherFatherGrandmotherGrandfather
High Blood Pressure

MotherFatherGrandmotherGrandfather
Cancer

MotherFatherGrandmotherGrandfather
Heart Disease

MotherFatherGrandmotherGrandfather
Diabetes Type-1

MotherFatherGrandmotherGrandfather
Diabetes Type-2

MotherFatherGrandmotherGrandfather
UNKNOWN

MotherFatherGrandmotherGrandfather
ALLERGIES: Please CHECK any of the following to which you've had ALLERGIC REACTIONS to:
NO KNOWN DRUG ALLERGIES
AspirinCodeineIodineLatexLocal Anesthetics (Novocain)PenicillinSulfurAdhesiveOther
MEDICATIONS: Are you currently taking any medications?
NONE AT THIS TIME
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
Medication #11
Medication #12
Medication #13
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.
Signature*

Clear
(if the patient is a minor, the legal guardian must sign)
Current Date

MonthDayYear
Q
K
Bundle
Should be Empty:

PATIENT MEDICAL INFORMATION

WHAT BRINGS YOU IN TO SEE US TODAY?

PAST MEDICAL HISTORY

Past SURGERIES with date:

Past HOSPITALIZATIONS with date:

SOCIAL HISTORY

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

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

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

MEDICATIONS: Are you currently taking any medications?