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
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