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Transcript
Patient’s name: Social History: Height: Tobacco? Never No Yes Alcohol? Never Rare Occasional Family History: Diabetes Heart Disease Weight: Shoe Size: Packs per day? For (how many) years? Daily Cancer Unknown None Other PRIMARY CARE PHYSICIAN Doctor’s Name: Phone # ( Check here if None ) ALLERGIES Anesthetics Penicillin Quit When? Aspirin /Anti-Inflammatory Medications Sulfa Seafood Latex Check here if None Codeine Tape Demerol Erythromycin Iodine Other: Metal (Nickel) ________ REASON FOR EVALUATION / TREATMENT Please briefly describe why you are here today. Left Right Both feet How long? Prior Treatment? By Dr. PAST SURGICAL HISTORY (please list surgeries below) Y N _____________ Check here if None Surgeries: CHECK ALL that apply either PAST or PRESENT Artificial Joints Artificial Valves Asthma Blood Clots Cancer (Type _________) Cholesterol Problems Circulation Problems in legs Dementia Depression / Anxiety Diabetes Fibromyalgia Glaucoma Gout Headaches Heart Problems (attack / chest pains/murmur /irregular beat/ congestive heart failure/ mitral valve prolapsed/ valve disease Hepatitis High Blood Pressure Check here if None HIV / AIDS Kidney Problems (Stones/ infection /failure/dialysis) Liver Problems Lung Breathing Problems Neurological Disorders Osteoarthritis Osteoporosis Parkinson’s Disease Peripherial Neuropathy Prostate Problems Psoriasis / Eczema Rheumatoid Arthritis Stomach / Intestine (Ulcer / acid reflux) Stroke Substance Abuse Thyroid Disease Ulcers (Diabetic) Varicose Veins Other Medical History (Please List): DO YOU CURRENTLY HAVE ANY OF THE FOLLOWING Nausea Diabetic? Vomiting Y N Diarrhea Test Blood Sugars? Fever Y Chills Night Sweats Shortness of breath Range? Low N How Often? to High Chest Pain HA1C: MEDICATIONS: If you have a completed list, please give to receptionist to copy. Medication Dose Frequency 1. 2. 3. 4. 5. 6. 7. Patient/Guardian Signature Date