Podiatry Group, P.a. Medical History Form
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1PODIATRY GROUP, P.A.
MEDICAL HISTORY FORM
Who is your primary care doctor? ____________________________ Phone number __________________________
When were you last seen by this doctor? ___________________________________
If you are under the regular care of any other doctors, or see an endocrinologist or vascular surgeon, please list their
names: ________________________________________________________________________________________
MEDICAL HISTORY (Check all that apply)
AIDS/HIV
___
Diabetes
___
High Blood Pressure
___
Stomach ulcers
___
Anemia
___
Epilepsy
___
High Cholesterol
___
Thyroid problems
___
Arthritis
___
GERD
___
Kidney Disease
___
Tuberculosis
___
Asthma
___
Gout
___
Liver Disease
___
Valve/Joint replacement ___
Bleeding problem___
Heart Disease ___
Phlebitis
___
Varicose veins
Cancer
___
Hepatitis
___
Stroke
___
Other ___________________
CURRENT MEDICATIONS:
______________________________
______________________________
_____________________________
______________________________
______________________________
_____________________________
______________________________
______________________________
_____________________________
HAVE YOU EXPERIENCED…
YES
NO
YES
NO
Back problems
___
___
Headaches
___
___
Burning, tingling or numbness in toes
___
___
Itchy skin on feet
___
___
Dryness of skin
___
___
Reaction to local anesthetic
___
___
Episodes of Fainting
___
___
Shortness of breath
___
___
Foot/leg cramps while sleeping
___
___
Swelling of Feet/Ankles
___
___
Foot/Leg cramps while walking
___
___
Keloid or thick scars
___
___
ALLERGIES: List allergies below -OR-
_____ Check if you have NO known drug allergies
A = true allergy
S = sensitivity
Adhesive Tape ____
Local Anesthetics
____
Sulfa Drugs
____
Aspirin
____
Shellfish
____
Penicillin
____
Demerol
____
Iodine
____
Codeine
____
Latex
____
Other ___________________
SURGICAL HISTORY (Procedure and year) __________________________________________________________
______________________________________________________________________________________________
SOCIAL HISTORY Previous/current Nicotine use YES NO
Alcohol abuse YES NO
Drug abuse YES NO
If yes to nicotine use, for how long? _________
When did you quit? _________
FAMILY HISTORY Diabetes ____ Heart Disease ____ Cancer ____ Keloid scars ____ Sickle cell disease ____
What is your chief foot/ankle/leg complaint today? ______________________________________________________
How long has it been bothering you? _________________If applicable, what was the date of injury?______________
Previous treatments? _____________________________________________________________________________
AAMC Health Services Building 2401 Brandermill Blvd. Suite 340 Gambrills, Maryland 21054
Telephone (410)451-3206 Fax (410) 451-3207
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