Date of Birth:
Reason For Your Visit: What is the Chief Complaint for which you came to be treated?
Medical History: (Check all that apply)
High Blood Pressure
Allergies (Check all that apply)
Have You Experienced....
Burning, tingling or numbness in toes
Dryness of skin
Episodes of Fainting
Foot/leg cramps while sleeping
Foot/leg cramps while walking
Itchy skin on feet
Reaction to local anesthetic
Shortness of breath
Swelling of Feet/Ankles
Keloid or thick scars
Surgical History (Procedure and year)
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?
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.
Should be Empty: