Do you have diabetes? oYes oNo If yes, do you take insulin? o Diabetes o Liver Disease o Varicose Veins o Arthritis o Bleeding Disorder o Diabetes …
Describe your foot
problem_____________________________________________________________________
_____________
____________________________________________________________________________
____________________________
Have you tried anything to treat the
problem?____________________________________________________________________
How long has it been bothering you? Days ____________ Weeks
____________ Months _________ Years_____________
Please indicate which foot problems you now have or have had in the past:
? Ankle Pain ? Athletes Foot ? Bunions
? Corns and Calluses ? Numbness in Feet or Legs ? Flat
Feet
? Foot or Leg Cramps ? Heel Pain ? Ingrown Toenails
? Plantar Warts ? Swelling in Ankles or Feet ? Tired Feet
Height ______________________ Current Weight ______________________ Shoe
Size _______________________
3 ALLERGIES 4
MEDICATIONS
Are you allergic to or sensitive to:
What medications do you take regularly?
Please include prescriptions,
over-the-
counter
? Adhesive/Tape ? Anesthetics
medications, and vitamins
_______________________________________________
? Anticoagulants ? Novocain
_______________________________________________
? Aspirin ? Penicillin
_______________________________________________
? Codeine ? Seafood
Name of Pharmacy or Drug Store:
? Demerol ? Sulfa
_______________________________________________
? Iodine ? Others __________ Phone
________________________________________
5 GENERAL HEALTH INFORMATION
Do you have diabetes? ?Yes ?No If yes, do you take insulin? ?Yes ?No
Number of years that youve had diabetes________
Please list any surgeries you have
had_________________________________________________________________________
__
____________________________________________________________________________
_____________________________
Hospitalizations other than for the surgeries
listed_________________________________________________________________
Are you under a physicians care? ?Yes ?No If yes, for what
condition?
___________________________________________
Physician_____________________________________ Date you last saw this
Doctor ___________________________________
May we contact your physician about your health? ?Yes ?No Physicians
Phone Number ___________________________
Do you smoke? ?Yes ?No Number of packs per day _________ How many
years have you smoked? __________________
Did you previously smoke? ?Yes ?No Number of years ____________
Do you drink alcohol or beer? ?Yes ?No If yes, how much? ?Less than
1-2 per week ?1-2 per day ?More than 2 per day
Do you drink caffeinated beverages? ?Yes ?No Number of cups/cans per
day___________
Employment: Sit at job _______ Stand at job ______ Stand walk at job
______ Retired ______ Homemaker ______
Athletic activities in which you participate please list and indicate
frequency_________________________________________
6 MEDICAL HISTORY
Please check which best describes your general health: ?Excellent ?Good
?Fair ?Poor
Please check any of the following you have, or have had a problem with in
the past:
? Aids/HIV ? Epilepsy
? Nose Problems
? Anemia ? Eye problems ? Phlebitis
? Angina ? Fainting/Dizziness ? Psychiatric
Disorders
? Arthritis ? Foot or Leg Cramps ? Respiratory Disorders
? Asthma ? Frequent Infection ? Rheumatic Fever
? Back Problems ? Gout ? Shortness
of Breath
? Bleeding Disorders ? Headaches ? Slow
or non-healing wounds
? Cancer ? Heart Disease ? Stomach
ulcers
? Chemical Dependency ? Hemophilia ? Stroke
? Chest Pain ? Hepatitis ?
Swelling of the feet/ankles
? Chronic Diarrhea ? High Blood Pressure ? Tuberculosis
? Circulatory Problems ? Kidney Disease ? Unexplained
fever / weight loss
? Diabetes ? Liver Disease ?
Varicose Veins
? Ear problems ? Neurological
Disorders ? Venereal Disease
Do you have any artificial joints?
Hip ? Yes ?
No Right / Left
Knee ? Yes ? No Right / Left
Do you have a Heart Valve Implant or Murmur? ? Yes ? No
Women Only: Are you pregnant? ?Yes ?No Breastfeeding? ?Yes ?No Taking
Oral Contraceptives? ?Yes ?No
7 FAMILY HISTORY
MOTHER Living ? Deceased ? Cause of Death
___________________________
FATHER Living ? Deceased ? Cause of Death
___________________________
BROTHER Living ? Deceased ? Cause of Death
___________________________
SISTER Living ? Deceased ? Cause of Death
___________________________
Is there a family blood relative history of any of the following medical
problems:
? Heart Disease ? Arthritis ? Bleeding Disorder
? Diabetes
? Neurological Disease ? Stroke ? Circulation problems of the legs
/ feet
? Bunions ? Hammertoes ? Flatfeet
8 CONSENT
I certify that the above information is true and correct to the best of my
knowledge I give my permission to the doctor to examine, administer and
after consultation, perform such procedures as may be deemed necessary in
the
diagnosis and / or treatment of my feet
Signature
Date
Source:air.org
