PATIENT NAME: ___________________________________________________
PODIATRIC HISTORY
What is the chief compliant for which you came to be treated? (Include foot, ankle, knee, thigh, and hip complaints.)
__________________________________
__________________________________
__________________________________
__________________________________

Have you ever been to a Podiatrist before?
Yes   No
If yes, please list.
Name _____________________________
Last Visit __________________________		 I there any personal or family history of diabetes?   Yes   No

Your occupation ____________________
Do you smoke cigarettes ______________
Years smoked ______________________
Do you drink alcohol _________________

Athletic activities in which you participate (please list and indicate frequency)
__________________________________
__________________________________
__________________________________

Please indicate which foot problems you now have or have had in the past.
Ankle pain Yes   No Athlete's Foot Yes   No
Bunions Yes   No Corns and Calluses Yes   No
Cramps foot/legs Yes   No Flat Feet Yes   No
Numbness feet/legs Yes   No Heel Pain Yes   No
Ingrown toenails Yes   No Plantar Warts Yes   No
Infections fees Yes   No Ulcerations Yes   No
Amputations Yes   No Swelling ankles/feet Yes   No
Other ____________________________________________________________


MEDICAL HISTORY
Place a mark on "Yes" or "No" to indicate if you have had any of the following:
AIDS/HIV Yes   No Anemia Yes   No
Angina Yes   No Arthritis Yes   No
Asthma Yes   No Artificial heart valves Yes   No
Back Problems Yes   No Bleeding disorders Yes   No
Cancer Yes   No Chemical dependency Yes   No
Chest Pain Yes   No Chronic diarrhea Yes   No
Circulatory problems Yes   No Diabetes Yes   No
Double/blurred vision Yes   No Ear Problems Yes   No
Epilepsy Yes   No Eye Problems Yes   No