HEALTH & SYMPTOMS FORM

DATE ______________________________

NAME ______________________________ DOB ____________ HOME PHONE______________________

FIRST MI LAST (DATE OF BIRTH)

Age _________ Weight _______________ Height _________ Shoe Size ____________

What is your medical problem today? _______________________________________________

Please list all medications you are currently taking: ______________________________________

Do you smoke? YES / NO HOW MUCH? ____________ Drink Alcohol? YES / NO HOW MUCH? _________

Family Physician’s Name: _________________________________ Date last seen: ______________

In Case of Emergency Call? _______________________________ Telephone # ________________

Have You Ever Been Treated For Foot Problems in the Past? YES / NO (circle one)

If Yes; What Was The Foot Problem? _______________________________________________________

Doctors Name: ______________________

Please Check If Your Are Allergic To Any Of The Medications Listed Below:

qI Have No Allergies to Any Medications
 

q	Aspirin	q	Novacaine	q	Iodine
q	Codeine	q	Sedatives	q	Penicillin
q	Sulfa	q	Narcotics	q	Barbiturates
q	Anesthetics	q	Adhesive Tape	q	Antihistamines

qOther (specify) ____________________________

Please Check If You Have Any Of The Following:

Other Medical Problem Not Listed Above:_____________________________________________________________

List Any Operations Which You Have Had In The Last 5 Years: ___________________________________________________

List Any Hospitalizations Which You Have Had In The Past 5 Years: _________________________________________________

WOMEN: Are You Currently Pregnant? YES / NO (circle one)

Are You Currently Taking Birth Control Pills? YES / NO (circle one)

Carolina Foot Specialists | Raleigh - Durham - Cary - Clayton - Knightdale