Paradise Podiatry Group
Robert M. Victor, DPM, FACFAS
Patient Name: ____________________________________
Date: ___________________
Reason for being seen: _________________________________________________________________
How long have you been bothered by the above? ____________________________________________
What have you done for your foot problem? ________________________________________________
Type of pain (circle all that apply):
sharp, dull, aching, throbbing, burning, shooting,
continuous, intermittent, localized, other: _____________________
Have you ever had, or been treated for, any of the following?
Major Disease
Vascular
HEENT
□ Diabetes
□ Anemia
□ Glaucoma
□ High Blood
□ Leg Pain When
□ Headaches
Pressure
Walking
□ Hearing Loss
□ Angina
□ Prolonged
Miscellaneous
(Chest pain)
Bleeding
□ Bladder Problem
□ Heart Disease
□ Blood Clots
□ Cancer
(Type:_______)
□ Arrhythmia
□ Poor Circulation
Respiratory
□ Heart Murmur
□ Hepatitis/Liver
□
Asthma
Disease
□ Stroke
□ Emphysema
□ Fainting
□ High
Cholesterol
□ Tuberculosis
□ Epilepsy/Seizure
Gastrointestinal
Arthritis
□ HIV
□ Acid Reflux
□ Artificial Joints
□ Kidney Problem
□ GI or Rectal
□ Gout
□ Muscle Disease
Bleeding
□ Osteoarthritis
□ Prostate Problem
□ Bowel
□ Rheumatoid
□ Thyroid Disease
Disorders
□ Fibromyalgia
□ Hernia
□ Ulcers
Psychological
□ Anxiety
□ Depression
□ Psychiatric Care
□ Alcohol Dependence
□ Drug Dependence
Other Medical Problems
□ ______________
□ _______________
□ _______________
Family History
□ Bleeding Disorder
□ Anesthesia
Complications
□ Heart Disease
□ Diabetes
□ Cancer
Are you taking medications? (please list below or attach a copy)
_____________________________________________________________________________________
_____________________________________________________________________________________
Allergies
□ Penicillin
Reaction? _______________
□ Latex:
Reaction? _______________
□ General Anesthesia
Reaction? _______________
□
□
□
Sulfa Drugs
Reaction? _______________
Adhesive Tape:
Reaction? _______________
NSAIDS:
Reaction? _______________
□
Codeine:
Reaction? ________________
□ Novocaine/Local Anesthetic:
Reaction? ________________
Others (Name/Reaction)
What operations have you had? ___________________________________________________________
Rev 7/1/14