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)
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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
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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
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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
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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)
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Acid Reflux
Arthritis
Asthma
Anemia
Back pain
Bleeding
Disorder
Cancer
Cataracts
Clots
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Height: ____________
COPD
Delayed
Healing
Diabetes
Emphysema
Epilepsy
Foot Fractures
GI ulcers
Gout
Heart Attack
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Heart Disease
Hepatitis
HIV
Hypertension
Joint Pain
Kidney disease
Dialysis
Liver disease
Lung disease
Neuropathy
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Pacemaker
Polio
Psoriasis
Rheumatic
Fever
Seizures
Sickle Cell
Stroke
Thyroid disease
Ulcers
Weight: _______________
Other: ____________________________________________________________________________________
Surgeries: None __________________________________________________________________________
__________________________________________________________________________________________
Medications: None ________________________________________________________________________
__________________________________________________________________________________________
ALLERGIES:
No Known
Reaction
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_________________
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_________________
Social History
Tobacco:
Yes
No
Alcohol:
Yes
No
Not anymore
How long? __________ # of cigarettes per day?_______
How many drinks per week? ____________
Family History: _____________________________________________________________________________
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