File - Foot and Ankle Center of Durham
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Foot and Ankle Center of Durham 3811 N. Roxboro St, Suite A, Durham, NC 27704 (919) 471-1002 What are you seeking treatment for? Name: ______________________ Date:_________ I hurt here: ___________________________________ For how long? ________________________________ Kind of Pain (circle all that apply): Dull Aching Sharp Burning Throbbing Radiating Tingling Shooting I feel pain when: ___________________________________________________________________________ I feel better when: __________________________________________________________________________ Prior treatment: ___________________________________________________________________________ Wound or Ulcer? Any injury or trauma? Xrays? Yes No Yes No Yes Drainage or weeping? Yes No No What happened? ____________________________________________ Does pain make you limp? Yes No Pain Level (1-10): __________ Review of Systems (Check ones you currently have or had in the past 6 month) Musculoskeletal Arthritis Lower Back Pain Joint Stiffness Restricted Motion Arch Pain Bunions Corns/Calluses Hammer Toes In-Toeing Neuroma Toe Walking Joint Pain Knee Pain Muscle Cramps Weakness Broken Ankle Flat Feet Heel Pain Joint Implants Orthotic Use Gout Back Problems Paralysis Ankle Sprain Broken Foot Bone Foot Problems as child Walking Problems High Arch Feet Muscle Stiffness Shoe Insert Use NEUROLOGY Burning Fainting Numbness Speech Disorders Strokes Tingling Tremors Unsteady Gait Black Outs Neuromas SKIN Eczema Itching Warts Dryness Hives Lumps Athlete's Foot Fungal Nails Ingrown Nails Keloid Scar Mole Changes Rash GI Constipation Liver Disease Excessive Thirst Swallowing Problem Hemorrhoids Diarrhea Rectal Bleeding Hepatitis Gall Bladder Disease Laxatives Jaundice Antacid Use Nausea Heart Burn CARDIOVASCULAR Extremity(s) Cool High Blood Pressure History of Heart attack Replacement heart valve Varicose Veins Heart Murmur Cramps in legs/feet Palpations Chest Pain Hair Loss on Legs Rheumatic Fever Leg or Foot Ulcers Vascular grafts PULMONARY Asthma Bronchitis COPD Wheezing TB Pleurisy Short of Breath HEAD Pain Fainting Sweats Cough Headaches Dizziness OVERALL Chills Fatigue Fever Weakness Weight Gain Weight Loss NONE Foot and Ankle Center of Durham 3811 N. Roxboro St, Suite A, Durham, NC 27704 (919) 471-1002 Medical History: (Check all you have or have had in the past) Acid Reflux Arthritis Asthma Anemia Back pain Bleeding Disorder Cancer Cataracts Clots Height: ____________ COPD Delayed Healing Diabetes Emphysema Epilepsy Foot Fractures GI ulcers Gout Heart Attack Heart Disease Hepatitis HIV Hypertension Joint Pain Kidney disease Dialysis Liver disease Lung disease Neuropathy Pacemaker Polio Psoriasis Rheumatic Fever Seizures Sickle Cell Stroke Thyroid disease Ulcers Weight: _______________ Other: ____________________________________________________________________________________ Surgeries: None __________________________________________________________________________ __________________________________________________________________________________________ Medications: None ________________________________________________________________________ __________________________________________________________________________________________ ALLERGIES: No Known Reaction _________________________ _________________ _________________________ _________________ _________________________ _________________ _________________________ _________________ Social History Tobacco: Yes No Alcohol: Yes No Not anymore How long? __________ # of cigarettes per day?_______ How many drinks per week? ____________ Family History: _____________________________________________________________________________ __________________________________________________________________________________________
