carolinapodiatry.net - New Patient Paperwork

Name:

First NameLast Name

What is the reason for your visit today?

ALLERGIES:

FOODINSECTSDRUG ALLERGIES

Mention Foods:

Mention Insects:

Mention drug allergies:

WHAT MEDICATIONS ARE YOU TAKING?

May we send your prescriptions electronically?

YESNO

PHARMACY NAME:

PHONE:

Please enter a valid phone number.

PHARMACY ADDRESS:

PAST MEDICAL HISTORY:

CHECK CONDITIONS YOU CURRENTLY HAVE OR HAD IN THE PAST.

Cancer: Type

Hepatitis: Type

PAST SURGERIES:

PLEASE LIST ALL SURGERIES THAT YOU HAVE HAD (NOT JUST FOOT RELATED):

FAMILY HISTORY:

DOES ANYONE IN YOUR IMMEDIATE FAMILY HAVE ANY MAJOR MEDICAL PROBLEMS? IF SO, LIST WHO AND WHAT: (please state if alive or deceased)

SOCIAL HISTORY:

DO YOU DRINK ALCOHOL?

YESNO

IF YES, HOW OFTEN?

DO YOU SMOKE OR USE TOBACCO?

YESNO

IF YES, # OF PACKS/DAY?

HOW LONG?

YRS

IF YOU PREVIOUSLY SMOKED OR USED TOBACCO, HOW LONG SINCE YOU QUIT?

DO YOU OR HAVE YOU EVER USED ILLEGAL DRUGS?

YESNO

DID YOU GET A FLU SHOT THIS YEAR?

YESNO

REVIEW OF SYSTEMS: CHECK SYMPTOMS YOU CURRENTLY HAVE OR HAD IN THE RECENT PAST.

CONSTITUTIONAL

CARDIOVASCULAR

ENDOCRINE

INCREASED THIRSTINCREASED URINATIONCOLD INTOLERANCETHYROID TROUBLES

ENMT

DIFFICULTY HEARINGRINGING IN EARSSTUFFY/RUNNY NOSESORE THROAT

EYES

GI

GU

IMMUNOLOGIC

LYMPHATIC

SKIN

MUSCLE

NEUROLOGICAL

PSYCHIATRIC

RESPIRATORY

By signing below, you state that the information provided above is accurate to the best of your knowledge. You also understand that this information is being gathered for the purpose of treating your foot condition as it may be caused by or affected by other underlying medical conditions. We may also use this information to assist emergency personnel in treating you if a medical emergency should arise.

Signature of Patient or Legal Guardian

Clear

Date

INSTRIDE/CAROLINA PODIATRY GROUP, INC – PATIENT INFORMATION

INITIAL HEALTH HISTORY