stepaheadfootcare.com - New Patient Form

New Patient Form
Name:*
Date of Birth:*

MonthDayYear
Date
Primary Care Physician:*
Last Visit w/PCP:*
Endocrinologist:*
Last Visit w/Endo:*
Referred By:*
Please describe your problem (include date of injury if applicable):*
PAST MEDICAL HISTORY
Check all that apply:*

Frequent Headache/MigraineAnemia / Blood DisordersRheumatic FeverPneumoniaKidney DiseaseDrug/Alcohol AbuseDialysis MWF or T TH SaEpilepsy / SeizuresDiabetes Average Blood Sugar:Prolonged Bleeding TimeTuberculosisStomach DisorderEmphysemaThyroid / Parathyroid DiseaseHeart TroubleHigh Blood PressureStrokeArthritisChest Pain on Mild ExertionPsychiatric TreatmentGoutEmotional Problems / TensionBLOOD CLOTSAsthma / Hay Fever / Shortness of BreathTumor / Abnormal Growth / CancerProstate DisorderEar / Nose / Throat DisorderSexually Transmitted Disease
Has any FAMILY MEMBER had any of the following problems (Please indicate relationship):

If not applicable, please mark N/A
Cancer:*
Diabetes: *
Heart Trouble:*
High Blood Pressure:*
Kidney Disease:*
Stroke:*
Mental or Emotional Disease:*
Tuberculosis:*
Arthritis:*
Emphysema:*
BLOOD CLOTS:*
PATIENT INFORMATION
Do you currently smoke?*

YesNo
If yes, how many packs /day?
How many years?
Smoke previously?*

YesNo
If yes, how many packs/day?
How many years?
Year Quit:
Number of caffeine drinks per day:*
Amount of alcohol consumed per week?*
Please complete the following:
Height:*
Weight:*
Shoe Size:*
Occupation:*
Marital Status:*

SingleMarriedDivorcedWidowedOther
Exercise Type/Duration/ Frequency (Example: Walk 10 minutes 3X per week):*
ALLERGIES
Please check all allergies:*

Medications:Foods:TapesNovocainAnestheticsSilver/Nickel/Costume JewelryOther
Medications:
Foods:
What types of reactions have you experienced?*
MEDICATIONS
Please list all prescription and over-the-counter medications and the dosages:*
SURGICAL HISTORY
HEALTH REVIEW
Please circle any symptoms you have had in the past 3 months:
General*

FeverChillsFatigueWeight LossWeight GainN/A
Head*

HeadachesVisual ProblemsHearing ProblemsLight SensitivityNone of these
Cardiovascular*

Chest PainPalpitationsDizzinessSwelling of LegsNone of theseOther
Hematology*

AnemiaAbnormal Bleeding/BruisingBlood ClotsOther Blood DisorderNone of these
Respiratory*

Persistent CoughWheezingShortness of BreathNone of these
Gastrointestinal*

Difficulty SwallowingIndigestion/HeartburnAbdominal PainChange in Bowel HabitsNone of these
Urinary*

Painful UrinationFrequent Night-time UrinationBladder LeakageNone of theseOther
Musculoskeletal*

Join Pain/Swelling/StiffnessBack PainArthritisMuscle WeaknessNone of these
Skin*

Skin RashSuspicious LesionsItchingNone of these
Neurological*

Numbness of hands/feetSeizuresTremorsParalysisNone of these
Psychiatric*

DepressionAnxietyProblems SleepingMemory LossNone of these
Endocrine*

Heat/Cold IntoleranceHot FlashesChange in hair/skin textureNone of theseOther
The information provided here is true to the best of my knowledge. I authorize release of any previous medical records by fax, mail, or phone by either physician or hospital. Also, I hereby authorize the doctor or her assistants to initiate the diagnosis and treatment of my condition with x-ray, examination, or photographs of infections as necessary.
Patient Signature:*

Clear
Date:*

MonthDayYear
Date
I have personally reviewed the above information:
Physician Signature:*

Clear
Date:*

MonthDayYear
Date
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New Patient Form

PAST MEDICAL HISTORY

PATIENT INFORMATION

ALLERGIES

MEDICATIONS

SURGICAL HISTORY

HEALTH REVIEW