A L L F L O R I D A P O D I A T R Y, P. A. M A R C G. C O L A L U C E, D. P. M.
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- Osborne Singleton
- 5 years ago
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1 Chart No: A L L F L O R I D A P O D I A T R Y, P. A. M A R C G. C O L A L U C E, D. P. M. Please PRINT Clearly; No Cursive. PATIENT MEDICAL HISTORY FORM Name: Date: Date of Birth: / / Age: Sex: M F 1.) New Patient Established Patient 2.) Vitals to Be Taken From Medical Assistant MU 3.) Primary Doctor: MD DO Last Date Seen: / / 4.) Chief Complaint & Historical Patient Information: a. Why Are You Here Today? b. When Did This Problem Start? c. What Is Your Pain Level 1-10 (10 Being The Highest): d. Does Your Primary Doctor Examine Your Feet? Yes No e. Are You Currently Participating In Physical Or Occupational Therapy? Yes No i. If Yes, When Did You Receive Therapy? ii. If Yes, Where Did You Receive Therapy? f. Have You Seen A Podiatrist Before? Yes No i. If Yes, Please Give The Doctor s Name: g. Have You Had A Pedicure Before at a Spa/Salon Before? Yes No i. If Yes, When? ii. If Yes, Where? h. Are You Currently Using Any Device to Assist Walking or Standing? Yes No i. Please Check Which Device(s): 1. Leg Brace(s) 2. Cane/Staff 3. Walker 4. Wheelchair 5. Other: FF
2 Chart No: 5.) Past Medical History: Please Check If You Have, Or Had Had In The Past, Any Of The Following: Diabetes Type I Type II Arthritis Poor Circulation Low Back Pain Stroke Anemia Gout Asthma Liver Disorder Kidney Disease Keloids/ Thick Scars Heart Disease Lung Disorder Rheumatism Ulcers High Blood Pressure Bleeding Problems Broken Bones Which Bones: Other: FF 6.) Past Surgical History: a. Previous Injuries: Date: / / b. Previous Surgeries: Date: / / c. Previous Hospitalizations: Date: / / 7.) List of Current Medications With Dosages: If You Have A List, Please Turn It In To The Front Desk With This Paperwork. 8.) Family History: Please Check Any of The Following That Apply Diabetes Arthritis Heart Disease High Blood Pressure Cancer Mother Has/Had Father Has/Had Both Parents Have/Had Mother s: Date of Birth: / / Date Passed: / / Father s: Date of Birth: / / Date Passed: / /
3 Chart No: 9.) Personal/Social History: Please Check The Boxes That Apply: a. Smoking: MU Never Former; Date You Quit Smoking: / / Former, Current Status Unknown Current Smoker, Some Days Current Smoker, Everyday Unknown If you are a Current Smoker, Please Fill In the Fields Below: No. of Cigarettes per Day? How Many Years Have/Had You Been Smoking? Type of Tobacco/Nicotine Used: Cigarettes Cigars Pipe Chewing Tobacco E-Cigarette b. Alcohol Intake: Denies Alcohol Use Drinks Rarely Drinks Socially Drinks Daily Abusive Drinker Abusive Drinker, Not Now c. Caffeine Intake: Denies Rarely Occasionally Daily Coffee Caffeinated Soda Tea d. Marital Status: e. Sexual Activity: Yes No Single Partnership g. Race: f. Physical Married MU Status: Separated Athletic White Divorced Moderately Widow Active American Indian/Alaska Natives Sedentary Black/ African American Native Hawaiian/ Pacific Island American h. Asian Language: MU If You Are A Female, Are You Now Pregnant? Yes No MU Ethnicity: MU Hispanic or Latino OR Non-Hispanic or Latino What Type of Activity? English Spanish French Russian Dutch Italian German Chinese Japanese Other:
4 Chart No: 10.) Allergies: FF Mark All Allergies and/ Reactions: Adhesive Tape/ Metal/ Penicillin/ Latex/Natural Rubber/ Aspirin/ Sulfa Drugs/ Contrast Dye/Iodine/ Codeine/ Pollen/ Shellfish/ Local Anesthetics/ Other / Pharmacy Name: Phone: Pharmacy Address: To the best of my knowledge, I have answered the questions on this form accurately. I understand that providing incorrect information can be dangerous to my health. I understand that it is my responsibility to inform the doctor and office staff of any changes in my medical status. Thank you. Patient Print Name & Sign: Caregiver Print Name & Sign: Notes for the Doctor:.
5 A L L F L O R I D A P O D I A T R Y, P. A. M A R C G. C O L A L U C E, D. P. M. Please PRINT Clearly; No Cursive. PATIENT MEDICAL HISTORY FORM Name: Date: Click here to enter a date. Date of Birth: Click here to enter a date. Age: Sex: Choose an item. 1.) New Patient or Established?: Choose an item. 2.) Vitals to be taken by our Medical Assistant. MU 3.) Primary Care Doctor:, MD or DO Last Date Seen by Primary: Click here to enter a date. 1.) WHY ARE YOU HERE TODAY? WHEN DID THIS PROBLEM START? WHAT IS YOUR PAIN LEVEL 1 10? 2.) PREVIOUS INJURIES/ SURGERIES/ HOSPITALIZATIONS DATES OR YEAR? PLEASE CHECK IF YOU HAVE, OR HAD IN THE PAST, ANY OF THE FOLLOWING: DIABETES - WHAT TYPE? KELOIDS/THICK SCARS ARTHRITIS HEART DISEASE POOR CIRCULATION LUNG DISORDER LOW BACK PAIN RHEUMATISM STROKE ULCERS ANEMIA HIGH BLOOD PRESSURE GOUT BLEEDING PROBLEMS ASTHMA KIDNEY/LIVER DISORDER LIVER DISORDER BROKEN BONES WHAT BONES? OTHER:
6 3.) LIST CURRENT MEDICATIONS WITH DOSAGES. IF YOU HAVE A LIST, PLEASE TURN IT IN WITH THIS PAPERWORK. 4.) LIST ALLERGIES WITH REACTIONS: 5.) WHEN YOU HAVE A PHYSICAL EXAMINATION, DOES YOUR PRIMARY PHYSICIAN EXAMINE YOUR FEET? Y N 6.) ARE YOU CURRENTLY PARTICIPATING IN PHYSICAL OR OCCUPATIONAL THERAPY? Y N IF YES, WHERE? 7.) HAVE YOU SEEN A PODIATRIST BEFORE? Y N IF YES, PLEASE GIVE THE DOCTOR S NAME: 8.) HAVE YOU HAD A PEDICURE BEFORE? Y N IF YES, WHEN AND WHERE? 9.) ARE YOU CURRENTLY USING A WHEELCHAIR OR WEARING LEG BRACES? _ FAMILY HISTORY: PLEASE CHECK ANY OF THE FOLLOWING THAT APPLY MOTHER DIABETES ARTHRITIS HEART DISEASE HIGH BLOOD PRESSURE CANCER FATHER DATE OF BIRTH DATE OF BIRTH DATE OF DEATH DATE OF DEATH NAME: CHART # SEX: MALE FEMALE
7 SOCIAL HISTORY: PLEASE CHECK THE FOLLOWING THAT BEST DESCRIBES YOU. MARRIED SINGLE DIVORCED WIDOW ATHLETIC SEDENTARY MODERATELY ACTIVE WHAT TYPE? RACE: AMERICAN INDIAN/ALASKA NATIVES ASIAN BLACK/AFRICAN AMERICAN NATIVE HAWAIIAN/PACIFIC ISLAND AMERICAN WHITE PATIENT DECLINED ETHNICITY: HISPANIC OR LATINO NON HISPANIC OR LATINO PATIENT DECLINED LANGUAGE: ENGLISH SPANISH FRENCH RUSSIAN DUTCH ITALIAN GERMAN CHINESE JAPANESE OTHER SMOKING: CURRENT, EVERY DAY CURRENT, SOME DAYS FORMER NEVER FORMER, CURRENT UNKNOWN UNKNOWN WHAT IS YOUR SOURCE? HOW MUCH A DAY & FOR HOW MANY YEARS? NAME: CHART # PLEASE CIRCLE ONE ALCOHOL INTAKE DAILY OCCASIONAL RARELY - NONE CAFFEINE INTAKE DAILY OCCASIONAL - RARELY - NONE WHAT IS YOUR SOURCE?
8 ARE YOU SEXUALLY ACTIVE? YES OR NO IF YOU ARE FEMALE, ARE YOU NOW PREGNANT? Pharmacy Name Phone Pharmacy Address Notes for the Doctor: THANK YOU! NAME: CHART #
Patient Information (Please Print)
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Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: Spouse/Partner Name:
Practice: Today s Date: Name: DOB: Chart Number: Sex: Marital Status: ingle Married Widowed Divorced SS#: E-mail: Spouse/Partner Name: E-mail newsletters, reminders, statements, etc. Address: City: State:
Patient Interview Form
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Patient Interview Form
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Patient Interview Form
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HEALTH QUESTIONNAIRE
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Preferred(Nick) Name: Address: City State Zip Home Phone: Cell: Email: Date of Birth: Age: Social Security(last four #'s): Gender: Marital Status: O Single O Married O Divorced O Widowed Primary Care Physician:
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Patient Health History
Patient Health History Today s Date / / Signature of Patient Patient Title: (check one) Mr. Mrs. Ms. Miss Dr. Prof. Rev. First Name Nick Name Last Name Middle Name Suffix Address 1 Address 2 How did you
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