PATIENT NAME: ___________________________________________________
Fainting Yes   No Glaucoma Yes   No
Gout Yes   No Headaches Yes   No
Heart Disease Yes   No Hemophilia Yes   No
Hepatitis/Jaundice Yes   No High Blood Pressure Yes   No
Joint Pain Yes   No Kidney Problems Yes   No
Liver disease Yes   No Low Blood Pressure Yes   No
Nervous Problems Yes   No Phlebitis Yes   No
Psychiatric Care Yes   No Radiation Treatment Yes   No
Rash Yes   No Respiratory Disease Yes   No
Rheumatic Fever Yes   No Shortness of Breath Yes   No
Sinus Problems Yes   No Special diet Yes   No
Stroke Yes   No Swollen neck glands Yes   No
Thyroid Problems Yes   No Tired Feet Yes   No
Tuberculosis Yes   No Urination problems/infection Yes   No
Varicose Veins Yes   No Venereal Disease Yes   No
Weight gain Yes   No Weight loss, unexplained Yes   No


MEDICATIONS:
Include prescriptions, over-the-counter medications, vitamins, and herbal medicines:
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________

Pharmacy Name and Number: ___________________________________________

ALLERGIES: Are you allergic to any of the following:
Adhesive Tape Yes   No Anticoagulant Therapy Yes   No
Aspirin Yes   No Codeine Yes   No
Iodine Yes   No Local Anesthetics Yes   No
Penicillin Yes   No Sulfa Yes   No
Latex Yes   No Other: ____________________________


PRIOR SURGERIES: (List all surgeries including any foot surgery)
____________________________________________________________________
____________________________________________________________________

FAMILY HISTORY: (Blood relatives only, not family members related by marriage)
What illness/diseases run in your family: ____________________________________________________________________
____________________________________________________________________

I certify that above information is true and correct to the best of ny knowledge. I gave my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of ny feet.

Patient signature: __________________________ Date _____ / _____ / _____