Medical Form

Medical Form
Name

First Name Last Name
Date of Birth:

Month Day Year
Date
Reason For Your Visit: What is the Chief Complaint for which you came to be treated?
Medical History: (Check all that apply)

AIDS/HIV Anemia Arthritis Asthma Bleeding Problem Cancer Diabetes Epilepsy GERD Gout Heart Disease Hepatitis High Blood Pressure High Cholesterol Kidney Disease Liver Disease Phlebitis Stroke Stomach Ulcers Thyroid problems Valve/Joint Replacement Varicose Veins
Current Medications
Allergies (Check all that apply)

Adhesive/Tape Anticoagulant Therapy Aspirin Codeine Demerol Iodine Latex Local Anesthetics Novocaine Penicillin Seafood Sulfa
Have You Experienced....

Back Problems Burning, tingling or numbness in toes Dryness of skin Episodes of Fainting Foot/leg cramps while sleeping Foot/leg cramps while walking Headaches Itchy skin on feet Reaction to local anesthetic Shortness of breath Swelling of Feet/Ankles Keloid or thick scars
Surgical History (Procedure and year)
Social History
Smoking: Do you or have you ever smoked? If yes, how many years? How long ago did you quit?
Alcohol Use: Do you or did you ever drink alcoholic beverages? How many drinks do you consume in a day? Week? How long ago did you quit?
Recreational Drug Use: Do you or have you ever used illicit/recreational drugs? If yes, which ones? How long ago did you quit?
Women: Are you currently pregnant?

Yes No Not sure
Consent for Treatment *

I certify that the information above is true and correct to the best of my knowledge. I hereby consent and give my permission to the doctor (and the doctor’s assistants or designated replacement) to administer and perform such procedure upon me as the doctor deems necessary.
Signature

Clear
Should be Empty:

Medical Form

Social History