‫تــقييـم مـــــريـض جـــراحـة القــدم والـكــاحـل الجـــديـد فـي العــيـادة الخــارجية‬
NEW OUT-PATIENT FOOT & ANKLE PATIENT ASSESSMENT
Date
/
/
Gender:  Male
14 H
Time ___ : ___ am/pm
 Female
Date of Birth __________ Age ________ Address(City) _______________ Telephone ___________________
Email Address __________________________________
What is your chief complaint for seeing the Foot & Ankle specialist today?______________________________
_________________________________________________________________________________
How long has this problem (pain) been present____________________________________________________
Has the problem (pain) worsened recently?  Yes  No
What would you say started the problem (pain) Injury Exercise Accident Spontaneous  Others____
Location of the pain: (Diagram)
RIGHT Foot
LEFT Foot
Please circle the severity of your pain on the scale below (0=no pain, 10=maximum pain)
0
1
2
3
4
5
6
7
8
9
10
|_______|______|______|______|______|______|_____|______|______|______|
| ‫مدينة الملك عبدهللا الطبية بالعاصمة المقدسة‬
1
How would you describe the pain?  Sharp  Dull  Burning  Aching
Does anything make your problem worse? Explain_________________________________________________
Does anything help with easing the pain? Explain__________________________________________________
Please check any treatment that you have tried and the result of this treatment for your pain
 Surgery
 Medications
 Physiotherapy/Exercise
 Massage/Ultrasound
 Steroid Injections
 Other injections
 Cast
 Walker boot
 Off the shelf brace
 Custom made brace
 Off the shelf shoe insert
 Custom moulded shoe insert
 Others _____________________
Have you seen any other physicians for this problem?  Yes  No
If yes, please specify in the table below which speciality and what treatment was administered?
Physician
Specialty
City
Treatments
Please list your current medications below
Medication
Dose
Reason
Do you have any allergies to medications?  Yes  No
If yes, what type of reaction: rash  swelling  wheezing shock
| ‫مدينة الملك عبدهللا الطبية بالعاصمة المقدسة‬
2
SURGICAL HISTORY
Have you ever had general anesthesia?  Yes  No
Please list any other surgical procedures you have had performed?
Surgeon/Hospital
Operation
Date
Social History
Marital Status:  Single  Married
Work Status:  Employed/self employed  Unemployed  Retired  Disabled  Other
Current or Past Occupation _________________
Which describes your tobacco use: Never Cigarettes Cigar Pipe  Chew/smokeless tobacco
Do you suffer from any of the following:fracture Osteoarthritis Gout Rheumatoid Arthritis 
Osteoporosis
Systems Review
Do you suffer from any of the following conditions
 Diabetes:  Diet  Oral medications  Insulin
HBA1C level if known ___ Date of test _________
 Blood clot in leg or lungs
 Bleeding disorder
 Heart attack
 High blood pressure
 Poor circulation
 Stomach ulcer
 Liver disorder
 Fever for unknown reason
 Unintentional loss of weight and appetite
 Neuropathy/changed sensation
  Tuberculosis
Patient’s Name: _____________________________________
Or Name of Delegate: ________________________________ Relationship: _________________
| ‫مدينة الملك عبدهللا الطبية بالعاصمة المقدسة‬
3