Download CARDIOVASCULAR (please circle)

ENCINITAS PODIATRY GROUP
James P. Hatfield, DPM inc
S. Luke Berthelsen, DPM
NAME
How did you hear of our office?
Primary Care Physician:
Previous Podiatrist:
501 North El Camino Real, Suite 201
Encinitas, California 92024
PAST MEDICAL HISTORY
760.436.8667
DATE OF BIRTH:
DATE:
Relationship:
Specialist:
_______
PLEASE MARK NO Ο IF NO CONDITION IS CIRCLED IN A SECTION
. . . . . . . . . . . . . . . . . . . . . . Ο NO CARDIOVASCULAR PROBLEMS
CARDIOVASCULAR (please circle)
Heart Attack
Angina (Chest Pain)
Heart Murmur
Heart Failure
Heart Surgery
Pacemaker
Vascular Disease
Vascular Surgery
Bruise Easily
Bleed Easily
NEUROLOGICAL (please circle)
Stroke
Epilepsy /Seizures
Peripheral Neuropathy Reflex Sympathetic Dystrophy
Rheumatic Fever
Palpitations
Heart Disease
Mitral Valve Prolapse
Hypertension
Anti-Coagulant Medication
Deep Vein Thrombosis/Phlebitis
Reynaud’s Syndrome
Ο NO NEUROLOGICAL PROBLEMS
Mental Disorders
Depression
Loss of Sensation / Numbness
Dementia/Alzheimer’s
. . . . . . .. . . . . . . . . . . . . . . . .
Parkinson’s Disease
GASTROINTESTINAL (please circle)
Gastric Reflux-GERD
Stomach Ulcer
MUSCULOSKELETAL (please circle)
Arthritis
Rheumatoid Arthritis
Back Problems
Implants in the Body (where?):
SKIN (please circle)
Psoriasis
CRST Syndrome
ENDOCRINE (please circle)
Thyroid Problems
Diabetes, SELF: (Type I or Type II)
OTHER (please circle)
Cancer
Glaucoma
Current Infections
MRSA Infection
Venereal Disease
AIDS / HIV
. . . . . . .. . . . . . . . . . . . . .
Intestinal Disease
. . . . . . .. . . . . . . . . . . . . .
Artificial Joints
Ο NO GASTROINTESTINAL PROBLEMS
Liver Disease
Hepatitis
Ο NO MUSCULOSKELETAL PROBLEMS
Sciatica
Gout
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ο NO SKIN PROBLEMS
Venous Dermatitis – Legs
. . . . . . .. . . . . . . . . . . . . . . . . . . .
Skin Cancer
Eczema
Ο NO ENDOCRINE PROBLEMS
Diabetes in Family (who?)
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Ο NO OTHER PROBLEMS
PLEASE LIST IF NOT LISTED ABOVE:
CURRENT MEDICATIONS (please circle)
Kidney Disease
Allergies / Hives
Drug / Alcohol Addiction
Lupus
Organ Transplant
. . . . . . . . . . . . . . . . . . . . Ο NOT TAKING ANY MEDICATIONS
Anti-Coagulant Medication: Aggenox Aspirin
Coumadin (Warfarin)
Plavix
Pradaxa
Ticlid
Xarelto
Anti-Inflammatory Medication
Antibiotics
Arthritic Medications
Prednisone / Cortisone Medication
Immunosuppressive Medications Statin Medications
Thyroid Medications
Vitamin E
Other Medication (please list):
ALLERGIES (please circle)
Ο NO KNOWN ALLERGIES
Aspirin
Penicillin
Codeine
Vicodin
Demerol
Antibiotics
Sulfa Drugs
Novocain
Anesthetics
Iodine
Adhesive Tape
Latex
. . . . . . .. . . . . . . . . . . . . . . . . . . . . . .
Other Allergies (please list):
SOCIAL Do you drink alcohol? Ο YES Ο NO # Glasses/Week
WOMEN Are you pregnant? Ο YES Ο NO If yes, which month?
Do you Smoke? Ο YES ΟNO Cigarettes/Day
Are you nursing? Ο YES Ο NO
I certify that the above information is COMPLETE and ACCURATE.
PATIENT’S OR REPRESENTATIVE’S PRINTED NAME
RELATIONSHIP
PATIENT’S OR REPRESENTATIVE’S SIGNATURE
DATE