Healthcare Questionnaire

 

PATIENT NAME: _____________________________________________________ DOB: __________________

 

Who Referred You To Our Office?   ______________________________________________________________ 

 

Primary Care Physician:   Name: ______________________________________ Last Visit Date: _____________

 

Referring Physician:          Name: ______________________________________ Last Visit Date: _____________

 

Podiatry/Foot/Ankle Complaint:

 

Why are you here today? __________________________________________________________________________

Where is the problem area?  ________________________________________________________________________

How long have you had this problem? ________________________________________________________________

Have you been seen by our physicians in the past?    No    Yes---If yes, When? ________________________________

Have you been evaluated or treated for this problem elsewhere?              No    Yes-- If yes, When? ______________________

                                    and Where?  _________________________________________________________________

Ambulation:        [  ] None      [  ] Crutches       [  ] Walker       [  ] Wheel Chair      [  ] Cane       [  ] Scooter   

 

 

PERSONAL MEDICAL HISTORY:  Please Check All That Apply

[  ]  AIDS/HIV                                       [  ]  Congestive Heart Failure             [  ]  Hemophilia                                     [  ]  Radiation/Chemo          

[  ]  Alcoholism                                     [  ]  Depression                                     [  ]  Hepatitis – A  B  C                        [  ]  Respiratory Disease * 

[  ]  Allergies/Hay Fever                      [  ]  Diabetes *                                      [  ]  High Blood Pressure                     [  ]  Rheumatic Fever

[  ]  Alzheimer’s                                    [  ]  Drug/Chemical Dependency       [  ]  High Cholesterol                           [  ]  Sinus Problems *

[  ]  Anemia                                            [  ]  Ear Problems  *                             [  ]  High Triglycerides                        [  ]  Skin Problems *

[  ]  Arthritis *                                       [  ]  Eye Problems *                              [  ]  Kidney/Bladder Problems *         [  ]  Sleep Apnea

[  ]  Asthma *                                        [  ]  Fibromyalgia                                  [  ]  Liver Disease *                              [  ]  Stroke

[  ]  Back Problems *                            [  ]  Gallbladder Disease                      [  ]  Low Blood Pressure                      [  ]  Thyroid Problems *

[  ]  Bleeding Disorders *                    [  ]  GERD/Hiatal Hernia                      [  ]  Medical Implants *                       [  ]  Tuberculosis (TB)

[  ]  Blood Clots/DVT/PE *                 [  ]  GI Ulcers                                         [  ]  Osteopenia                                     [  ]  Varicose Veins

[  ]  Cancer *                                          [  ]  Gynecological Problems *           [  ]  Osteoporosis                                 [  ]  Venereal Disease *

[  ]  Chronic Diarrhea *                        [  ]  Headaches                                      [  ]  Nervous System Disorder *        [  ]  Vertigo

[  ]  Circulatory Problems *                 [  ]  Heart Disease *                             [  ]  Psychiatric Care *                         [  ]  Other: ____________

 

INFECTIONS:   List current or previous infections

[  ] MRSA: date ____________  [  ] Hepatitis B: date _____________   [  ] Hepatitis C: date _____________

 

[  ] TB: date  ______________   [  ] Other:  __________________________________   date _____________

 

HOSPITILIZATIONS & SURGERIES:

Have you been hospitalized or had any surgeries in the past?     No             Yes---Please list below

 

1) ______________________________ Date: _________  4) ______________________________ Date: _____________

2) ______________________________ Date: _________  5) ______________________________ Date: _____________

3) ______________________________ Date: _________  6) ______________________________ Date: _____________

 

MEDICATIONS:

 

Do you currently take oral contraceptives?     No    Yes---Medicine Name: ________________________

Please check if no medications are currently being taken.   [  ] None

 Please list all prescribed and over the counter medications

 (including vitamins/supplements) you are currently taking

Name of Medication                                                                           Dosage                                        How often do you take

1.       _________________________________________        __________________             __________________________

2.       _________________________________________        __________________             __________________________

3.       _________________________________________        __________________             __________________________

4.       _________________________________________        __________________             __________________________

5.       _________________________________________        __________________             __________________________

6.       _________________________________________        __________________             __________________________

Pharmacy Name: ____________________________________________Phone #: ___________________________

Pharmacy Address: _____________________________________________________________________________

 

ALLERGIES:    Please Check All That Apply

 

[  ] Iodine  [  ] Penicillin  [  ] Latex  [  ] Aspirin  [  ] Adhesive Tape  [  ] Demerol  [  ] Codeine  [  ] Sulfa

[  ] Local Anesthetics (Novocain)   [  ] Seafood   [  ] No Known Allergies   [  ] Other: __________________

FAMILY HISTORY:   Please Check All That Apply

   [   ] Heart Disease     No    Yes---Relationship:     Father   Mother   Brother   Sister    Son    Daughter  

   [   ] Cancer                No    Yes---Relationship:     Father   Mother   Brother   Sister    Son    Daughter  

   [   ] Diabetes              No    Yes---Relationship:     Father   Mother   Brother   Sister    Son    Daughter  

   [   ] Other: _________________    Relationship:     Father   Mother   Brother   Sister    Son    Daughter  

SOCIAL HISTORY:

Marital Status:     [  ] Single    [  ] Married     [  ] Widowed    [  ] Divorced     [  ] Other

Occupation: ___________________________________________________________________________

Do you participate in any exercise regimen on a regular basis?         

       No       Yes …If yes, what type and how often? ___________________________________________________

Do you currently smoke or chew tobacco?

       No… If no, any past tobacco use?    No    Yes ---If Yes----Year stopped: ______ Years smoked: ______                            

       Yes… If yes, how many/much per day? ____________ Year started: __________

Do you consume any alcohol?     No    Yes…If yes, how much and how often? _____________________________

Current Height: __________ (Ft)       Current Weight: __________ (Lbs)        Shoe Size: __________     N   M   W

 

CERTIFICATION:

I certify that the information provided above is true, correct, and complete to the best of my knowledge, information, and belief.

_____________________________________________                  ___________________________________

Signature of Patient or Legal Guardian                                                                   Date Signed

_____________________________________________

Printed Name of Patient or Legal Guardian