Patient Medical History Form Page 5

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Patient Name
Date:
:
PAST SURGICAL HISTORY/HISTORY OF HOSPITALIZATIONS
Please describe any surgeries or hospitalizations that you have had, if any.  NONE
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
 NONE
Past History of any foot problems (not discussed above):
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
FAMILY HISTORY
Do you have a family history of any conditions such as Diabetes, Heart Disease, Blood Clots, Bleeding
Problems, Strokes, Gout?  NO.
If Yes, which condition and which family member? Also list any conditions not listed above:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
SOCIAL HISTORY
What is your occupation?________________________________________________________________
Does your occupation/lifestyle require you to spend large amounts of time on your feet? If yes, please
describe______________________________________________________________________________


Do you exercise?
NO
Yes (how often and how much) ____________________________________


Have you ever smoked?
NO
Yes


Do you currently smoke?
NO
Yes (Amount and how long)_________________________________


Do you drink alcohol?
NO
Yes (how often and much)____________________________________


Do you drink caffeinated beverages?
NO
Yes (how often and much)_________________________


DO YOU USE ILLICIT DRUGS SUCH AS MARIJUNA, COCAINE…
NO
YES
(EXPLAIN)______________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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