Download Pain Type: Aching / Throbbing / Shooting / Sharp / Stabbing

I.Cristina Verlezza, D.P.M.
*
Scott M. Cohen, D.P.M.
NAME:_______________________________________________DATE OF BIRTH:______________________AGE:________
REASON FOR TODAY’S VISIT
_______________________________________________________________
Heel Pain
Plantar Fasciitis
Ingrown Toenail
Warts
Neuroma (Pinched nerve)
Fractures
Nail Fungus
Athlete’s foot
Bunion
Hammertoes
Callus
Ankle Pain
Pain Type:
Aching / Throbbing / Shooting / Sharp / Stabbing
Pain Score: _______ (0-No pain; 10- The worst pain you have ever felt)
Height _______ Weight_______ Shoe Size_______
MEDICAL HISTORY (Past and/or Current-Check those that apply)
High Cholesterol
Kidney Disease
Liver Disease
Acid Reflux/Stomach Ulcers
Thyroid Disease
Epilepsy/Seizures
Arthritis
Lupus
Charcot Joint
Gout
Leg/Foot Cramps
Asthma
Hepatitis A, B, C
HIV/AIDS
Osteoporosis
Rheumatic Fever
Auto Immune Disease
Anxiety/Depression
Drug/Alcohol Abuse
Glaucoma/Cataracts
Peripheral Vascular Disease
High Blood Pressure
Anemia/Blood Disorders
Varicose Veins
Skin problems
Psoriasis
Blood Clots - year:
Heart Problems - Specify:
Stroke - year
Cancer - Type:
Year:
Diabetes - Circle: Type I or II - for
Neuropathy
yrs?
Other:_______________________________________________________________________________________________________
IF DIABETIC:
Doctor that manages your diabetes?______________________________ City__________________Phone#___________________
EXACT date last seen (mm/dd/yy)_____________________ Last Hemoglobin A1C _______ Blood Glucose this Morning_________
SURGICAL HISTORY (Check those that apply)
YEAR
YEAR
YEAR
YEAR
Angioplasty
Carotid Artery
Hernia repair
Vein Ligation
Appendectomy
Cataract
Kidney surgery
Foot surgery
Ankle surgery
D&C
Mastectomy
Metal in Body
Arterial By-pass
Gallbladder Surgery
Open Heart surgery
Pacemaker
Back surgery
Hysterectomy
Prostate surgery
Breast Biopsy
Hip surgery
Tonsillectomy
C-section
Knee Surgery
Stents (heart/legs)
Other:_______________________________________________________________________________________________________
1
ALLERGIES (Check those that apply)
No Known Drug Allergies
Reaction
Reaction
Aspirin
Anesthetics
Adhesive/Tape
Codeine
Reaction
Cortisone
Iodine/Betadine
Latex
Penicillin
Sulfa
Shellfish
FAMILY HISTORY (Circle if it applies)
Mother
Father
Siblings
Diabetes
Diabetes
Diabetes
Heart Disease
Heart Disease
Heart Disease
High Blood Pressure
High Blood Pressure
High Blood Pressure
Cancer - Type:
Cancer - Type:
Cancer - Type:
SOCIAL HISTORY (Check those that apply and explain)
No
Do you drink alcohol?
Any illicit drug use?
Do you smoke?
Did you ever smoke?
Are you pregnant?
Yes
If yes, how much?
If yes, explain
If yes, how much?
If yes, for how long?
If yes, when did you quit?
If yes, how far are you?
ARE YOU CURRENTLY EXPERIENCING ANY OF THE FOLLOWING? (Circle what applies):
GENERAL
HEAD & EYE
EAR/NOSE/THROAT
RESPIRATORY
GASTROINTESTINAL
URINARY
MUSCULOSKELETAL
SKIN
NEUROLOGICAL
ENDOCRINE
Fever
Dizziness
Hearing Loss
Asthma
Heartburn
Incontinence
Muscle aches
Rash
Numbness
Excessive hunger
Chills
Headaches
Sinus problems
Bronchitis
Diarrhea
Blood in urine
Weakness
Itching
Tics
Excessive Sweating
Diarrhea
Double vision
Tinnitus
Shortness of breath
Vomiting
Painful urination
Swollen joints
Dryness
Paralysis
Excessive thirst
Nausea/Vomiting
Fainting
Hoarseness
Emphysema
Ulcers
Frequent urination
Back pain
Sores
Tremors
MEDICATIONS
Name of Medication
Dosage (mg)
How many pills per day?
2
How many times per
day?