WSFAC Registration & Medical Questionnaire
This information is important for our records and your health Patient Name: _________________________________________
Primary Care Physician: __________________________ Phone # (___) ____-_________ May we contact your physician about your health?
Referring Physician: _________________________________________________________ Describe your current problem/complaint: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ How often does it bother you? _______________________________________________ Where on your foot does it bother you? _______________________________________ When does it bother you the most? ___________________________________________ How long does the pain last? ________________________________________________ What are your symptoms? __________________________________________________ What are the relieving factors? ______________________________________________ What aggravates it? _______________________________________________________ Pharmacy: _________________________ Phone#:_____________________________ MEDICATIONS
What medications are you currently taking? Please list all.
Any problems with local anesthetics? (Novocaine, Lidocaine)? Yes: _____ No: ______ Pharmacy: _______________________________ Phone #: _____________________________
PAST MEDICAL/SURGICAL HISTORY Any past medical problems on your feet and ankles? Please explain: _________________________________________________________________________________ _________________________________________________________________________________ Any past surgical procedures on your feet and ankles? Please explain: _________________________________________________________________________________ _________________________________________________________________________________ Have you had any serious illnesses? Please explain:
_________________________________________________________________________________ _________________________________________________________________________________ Please list any previous surgeries including date and physicians name: _________________________________________________________________________________ _________________________________________________________________________________ _________________________________________________________________________________ Check any of the following that you have, or have had a problem with: ____ Cardiovascular
____ Musculoskeletal ____ Integumentary (skin)
Patient Name: ___________________________________ Do you have Diabetes? ___ Yes ___ No If yes, do you take insulin? ___ Yes ___ No _____ Number of years? __________
Do you have any artificial joints?
Other: _____________________________________________________________________
Do you have a Heart Valve Implant? ___ Yes ___ No Do you have a Pacemaker?
Height: ____________________ Weight: ______________________ Shoe size: _______ SOCIAL HISTORY Do you smoke? ___ Yes ___No # of packs per day? ___ Previously smoked? ___ Yes ___ No
Do you drink alcohol? ___ Yes ___ No _____Light usage (1-2 per week) ___ Moderate (1-2 per day) ___Heavy ( > 2 per day ) Occupation: _____________________ Hobbies: ________________ Exercise: _________________ FAMILY HISTORY CONDITION RELATIONSHIP TO PATIENT
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