Medical History Form
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1Frank J. Cherpack, D.P.M.
8701 Shoal Creek Blvd., Suite 102, Austin, Texas 78757
Tel: (512) 343-8834 Fax: (512) 343-8854
MEDICAL HISTORY
Last Name:
First Name:
MI:
MEDICAL CONDITIONS (Please check all current and old diagnosis):
Yes No
Yes
No
Diabetes
Stroke
High Blood Pressure
Cancer or Tumor
Heart Valve Problem
Positive H.I.V. (AIDS)
Lung Problem
Hepatitis
Asthma
Any Joint Implants?
Liver Problem
Do you smoke? (Packs/Day:
)
Kidney Problem
Do you drink Alcohol?
Stomach Problem
Do you use street drugs?
Intestine Problem
Glaucoma
Epilepsy
Osteoarthritis
Anemia
Rheumatoid Arthritis
Do you take antibiotics prior to
Blood Clotting Problem
surgery?
Broken Foot or Ankle
Female Patient: Is there a possibility of
If yes, explain
you being pregnant today?
Other medical condition(s) not listed here:
List hospitalizations/surgeries in past:
ALLERGIES (to medication/drugs):
Yes No
Yes
No
Penicillin
Codeine
Sulfa Drugs
Iodine/Betadine
Aspirin
Novocain
Motrin (Ibuprofen)
Tapes/Adhesives
Other Anesthesia
Food Allergies
If yes, please list:
If yes, please list:
MEDICINES (List all medications you are now taking):
Frank J. Cherpack, D.P.M. – Medical History Form – 2009 – Rev. 1
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