Patient Information Update Form

Patient Information Update Form
Patient Name*
Patient Date of Birth*

MonthDayYear
Today's Date

MonthDayYear
Home Phone
Mobile Phone
Primary Care Doctor
Date Last Seen by PCP

MonthDayYear
Email Address
Have you had a Flu shot in the last 8 months?

YesNo
Pharmacy
Pharmacy Phone Number
Medical History
If none apply, please select:

None Apply
Medical Conditions:

Anemia/Blood Disease or DisorderAnxiety/DepressionArthritis/Rheumatoid/OsteoarthritisArtificial heart valves/Artificial jointsAsthma/Emphysema/Lung problemsAutoimmune Disease/HIV/AIDSBack problems/Herniated Discs/StenosisBlood ClotsBroken bones in feet/legsCancer (please specify below)Charcot JointChronic DiarrheaCirculation Problems/Varicose VeinsCVA (Stroke)/TIAsDiabetes (please specify below)DVT/PhlebitisEpilepsy/Fainting/SeizuresEye PathologyFibromyalgiaGastric Reflux/Hiatal HerniaGI Ulcers/Stomach ProblemsGoutHeart Disease/Angina/Chest PainHigh Blood PressureHigh CholesterolHypothyroidism/Thyroid ProblemsKidney disease/problemsLeg cramps/numbnessLiver disease/Hepatitis/JaundiceLupusMultiple SclerosisNeuropathyPeripheral Vascular DiseaseRheumatic FeverSkin Problems/PsoriasisWeight Change (loss/gain)
What type of cancer?
How many years have you had Diabetes?
If Over 65: Do you have a history of falls?

YesNo
Other Medical Problems (please list):
Surgical History
Have you had foot surgery?

YesNo
What type of foot surgery?
Foot surgery date:

MonthDayYear
Please indicate which side

RightLeft
Surgeries:

Angioplasty (please specify below)AppendectomyArterial Bypass (please specify below)Back SurgeryBreast Biopsy/LumpectomyC-SectionCarotid ArteryCataractD&CGall BladderHeart SurgeryHip/Knee ReplacementHysterectomyKidney RemovalKidney StoneMastectomyOpen HeartPacemakerProstateTonsillectomyVenous Ligation
Angioplasty (please indicate type)
Arterial Bypass (please indicate type)
Other Surgical History (please list)
Social History
Do you drink alcohol?

YesNo
If yes, what kind/s?
Do you use tobacco?

YesNo
If yes, how many packs per day?
Do you drink caffeine?

YesNo
If yes, how many cups/cans/bottles per day?
Do you use recreational drugs?

YesNo
If yes, what kind/s?
What activities (sports/exercise) do you do?
Height
Weight
Shoe size
Medications (please list both prescription and non-prescription medications & supplements)
Allergies

No Known Drug AllergiesAdhesive TapeAspirinCodeineCortisoneIodineLatexMotrin/AdvilNeosporinNovocainPenicillinSulfaOther
Q
K
Bundle
Should be Empty:

Patient Information Update Form

Medical History

Surgical History

Social History