Advanced Foot & Ankle Care, LLC. - Where we take it one step at a time!
Medical History Form
Patient Name:
Date of Birth:
What is your chief complaint?
Which side?
Right
Left
both
Type of pain:
Duration
Onset
What is your weight?
What is your height?
What is your shoe size?
Any previous injuries or problems to the feet, ankles, or legs?
yes
no
Has pain gotten:
What aggravates condition?
How long does pain last?
What have you tried to help the pain?
Have you ever had a similar pain?
yes
no
(describe, including treatment received)
In what athletic activities do you participate?
How many days per week do you exercise?
0
1 ~ 3
4 ~ 6
7
Do you wear store brought arch support?
yes
no
Do you wear custom orthotics?
yes
no
If yes, who made them?
How old are the orthotics?
Do you suffer from any of the following?....{check all that apply}
eating disorder
anxiety
depression
psychiatric
alcoholism
What is your occupation?
Do you smoke?
yes
no
Are you a past smoker?
yes
no
How many packs a day?
Years smoked?
List surgeries, serious injuries and illnesses not previously listed
Do you or your family suffer from any of the following? {Check all that apply}
Anemia
Arthritis:
Artificial Heart
Asthma
Back Problems
Bleed easily
Cancer
Chemical Dependency
Chest Pain
Circulatory Problems
Diabetes
Epilepsy
Fibromyalgia
Gout
Heart Disease
Hemophilia
Hepatitis
High Blood Pressure
HIV Positive
Kidney Problems
Leg Cramps
Liver Disease
Lung/Respiratory
Menopause
Mental Illness
Phlebitis / Clots
Psoriasis
Rheumatic Fever
Stroke
Thyroid Problems
Tuberculosis
Ulcers—Stomach
Venereal Disease
Weight Change,