Name: Sex: Male Female. Date of Birth: Occupation: Is this an accident or work related injury?

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Name: Sex: Male Female Date of Birth: Occupation: Is this a 2 nd opinion? Yes No Is this an accident or work related injury? Please list: Family MD: Referring MD: Address: Address: Phone: Phone: Fax: Fax: If a Worker s Compensation case, please give the name of person and address to receive reports: Claim Representative: Insurance Company: Address: Phone: 1. Please describe the problem which brings you to this office today: 2. How long have you had the problem? 3. How did the injury occur or problem begin? 4. Have you ever had a similar previous injury? Yes No If so, when? 5. Have you noticed any of the following changes or deformities in your feet? Bunions Corns Calluses Flatfeet Hammer toes High arches Toenail deformities Foot ulcers Other 6. Did you have flatfeet or any problems with your feet as a child? Yes No If so, what? *HCH1599* HCH 1599 Eff. 04/2007 Rev. 10/2008 Page 1 of 6 SS

7. Have you ever received for your foot or ankle problem: Surgery Shoe inserts Custom orthotics or braces Ankle wraps or braces Bunion/Hammertoe splint Corn pads Physical Therapy Cortisone shots, if so how many in each foot? MRI CT scan Medication, if so, what? 8. List in chronological order, with the appropriate dates, all doctors and/or podiatrists you have seen for your problem and any medications, appliances, surgeries or therapy you have received from them: 9. If you have had foot or ankle surgery, have you been satisfied with the results? Yes No If no, why not? 10. How would you describe the pain: None Mild Moderate Severe Sharp Dull Burning Other, describe 11. When does the pain occur? In the morning At night At rest With standing With exercise After exercise Other 12. Do you have any swelling in your foot or ankle? Yes No If so, where? 13. Do you have numbness of loss of sensation in your leg or foot? Yes No If so, where? 14. What (including different types of shoes) makes the pain/symptoms worse? 15. What (including different types of shoes) makes the pain/symptoms better? HCH 1599 Eff. 04/2007 Rev. 10/2008 Page 2 of 6 SS

16. Are there any activities that you can no longer perform because of your problem? 17. Have you lost time from work due to your problem? Yes No If so, how much? 18. Have you ever had a disability rating: Yes No If so, describe % 19. Do you have any work limitations? MEDICAL/SURGICAL HISTORY What is your current height? and weight? Allergies: Do you have any allergies to medications: Yes No If yes, please list the drug and type of reaction (hives, itching etc.) Current Medications: List all prescription, over the counter, and herbal medications that you are taking, please include the amount/dosage: Surgical History: List all the operations that you have had in your life, include the date: HCH 1599 Eff. 04/2007 Rev. 10/2008 Page 3 of 6 SS

Review of Systems: Any current or recent problems with the following: Yes No Describe your answers Eyes, Vision Ears, Nose, Throat Breathing Difficulties Chest Pain Digestion, GI Problems Bowel, Bladder Problems Blood Transfusions Blackouts, Fainting Muscle Weakness Muscle Spasms, Cramps Balance Problems Numbness, Tingling Psychological Problems Weight Loss or Gain Fevers or Chills Night Sweats Infections Other Medical Problems: Check all of the medical problems you have had in your lifetime: Anxiety or Depression Arthritis-Osteoarthritis/ Post-traumatic Arthritis-Rheumatoid/ Psoriatic/Lupus Asthma Bleeding Disorder Blood Clots Cancer (state type Diabetes Gastric Reflux (GERD) below) Heart Attack Heart Disease Irregular Heart Rhythm Hepatitis A B C High Blood Pressure High Cholesterol HIV/AIDS Kidney Disease Lung Disease Multiple Sclerosis Osteoporosis Parkinson s Disease Peripheral Vascular Polio Seizures Disease Sleep Apnea Stomach Ulcer Stroke Thyroid Disease Traumatic Brain Injury Tuberculosis (TB) Obstructive Sleep Apnea Snoring Daytime somnolence Please list any other medical problems: HCH 1599 Eff. 04/2007 Rev. 10/2008 Page 4 of 6 SS

Social History: Do you currently use tobacco? Yes No Did you previously use tobacco? Yes No Cigarettes packs/day Pipe Cigar Chewing tobacco For how long? yrs When did you quit? Do you drink alcohol? Yes No How often? History of substance abuse? Yes No What substance? Family History: Do you have any blood relatives with any of the following conditions? (Please indicate family member i.e. Mother =M, Father =F, Brother =B, Sister =S) Arthritis Asthma Blood Clots Cancer Diabetes Heart Disease High Blood Pressure Peripheral Vascular Stroke Disease Bunions Hammertoes Foot Ulcers Flatfeet High Arch Feet Other foot and ankle disorders Patient s or Guardian s Signature: Date MD Signature: Date VITALS: Temp BP HR HT WT Medical Assistant Signature: Date HCH 1599 Eff. 04/2007 Rev. 10/2008 Page 5 of 6 SS

HCH 1599 Eff. 04/2007 Rev. 10/2008 Page 6 of 6 SS

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