stepaheadfootcare.com - New Patient Form

New Patient Form
Name:
Date of Birth:

Month Day Year
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/Migraine Anemia / Blood Disorders Rheumatic Fever Pneumonia Kidney Disease Drug/Alcohol Abuse Dialysis MWF or T TH Sa Epilepsy / Seizures Diabetes Average Blood Sugar: Prolonged Bleeding Time Tuberculosis Stomach Disorder Emphysema Thyroid / Parathyroid Disease Heart Trouble High Blood Pressure Stroke Arthritis Chest Pain on Mild Exertion Psychiatric Treatment Gout Emotional Problems / Tension BLOOD CLOTS Asthma / Hay Fever / Shortness of Breath Tumor / Abnormal Growth / Cancer Prostate Disorder Ear / Nose / Throat Disorder Sexually Transmitted Disease
Has any FAMILY MEMBER had any of the following problems (Please indicate relationship):
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?

Yes No
If yes, how many packs /day?
How many years?
Smoke previously?

Yes No
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:

Single Married Divorced Widowed Other
Exercise Type/Duration/ Frequency (Example: Walk 10 minutes 3X per week):
ALLERGIES
Please check all allergies:

Medications: Foods: Tapes Novocain Anesthetics Silver/Nickel/Costume Jewelry Other
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

Fever Chills Fatigue Weight Loss Weight Gain
Head

Headaches Visual Problems Hearing Problems Light Sensitivity
Cardiovascular

Chest Pain Palpitations Dizziness Swelling of Legs Other
Hematology

Anemia Abnormal Bleeding/Bruising Blood Clots Other Blood Disorder
Respiratory

Persistent Cough Wheezing Shortness of Breath
Gastrointestinal

Difficulty Swallowing Indigestion/Heartburn Abdominal Pain Change in Bowel Habits
Urinary

Painful Urination Frequent Night-time Urination Bladder Leakage Other
Musculoskeletal

Join Pain/Swelling/Stiffness Back Pain Arthritis Muscle Weakness
Skin

Skin Rash Suspicious Lesions Itching
Neurological

Numbness of hands/feet Seizures Tremors Paralysis
Psychiatric

Depression Anxiety Problems Sleeping Memory Loss
Endocrine

Heat/Cold Intolerance Hot Flashes Change in hair/skin texture Other
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:

Month Day Year
Date
I have personally reviewed the above information:
Physician Signature:

Clear
Date:

Month Day Year
Date
Should be Empty:

New Patient Form

PAST MEDICAL HISTORY

PATIENT INFORMATION

ALLERGIES

MEDICATIONS

SURGICAL HISTORY

HEALTH REVIEW