Saul G. Trevino
Kyle Fiala
Ben Summerhays
Parvin Behrouzi
M.D.
D.P.M.
D.P.M.
F.N.P.-B.C.
Foot and Ankle Medical History Form
Date: _________________
Name: ___________________________ Age: ______ Date of Birth: ______/______/______
Referring Physician ______________________ Family Physician _________________________
Please circle area(s) involved: Foot Ankle Right Left Bilateral
Type of pain: Sharp Dull Achy Burning Radiating Constant Comes and goes
Please circle activity status: Unlimited walking Limited walking Unable to walk
Date of injury or duration of symptoms ___________ Work related? Yes _____ No _____
Please list any diagnostic studies for this condition, such as MRI, Bone Scan, Etc: ____________
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Have you seen anyone regarding this condition? Yes _____ No _____ if yes, list name: ______________
Have you ever been diagnosed with any of the following medical conditions:
Diabetes
DVT (Blood Clot)
High Blood Pressure
COPD
Alcoholism
Bleeding Tendencies
Rheumatoid Arthritis
Osteoarthritis
Anemia
Lupus
Sickle Cell Disease
Stomach Ulcers
Lung Disease
Polio
Tuberculosis
Yes
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No
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Heart disease
Fibromyalgia
Sleep Apnea
Hepatitis
Nervous System Disorders
Asthma
Cancer
Kidney Disease
Stroke
Migraines
Colitis
Epilepsy
Depression/Anxiety
Pelvic Radiation
Goiter
Yes
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No
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Other Medical Conditions: _______________________________________________________________
Are there law suits pending on your orthopaedic condition? Yes ____ No ____
(TURN OVER)
(TURN OVER)
(TURN OVER)
Please list any orthopaedic surgeries and dates:
Please list any other surgeries and dates:
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Please list all current medications and dosages:
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Are you allergic to:
Latex ___ Penicillin ___ Cephalosporin ___ Mycins ___ Sulfa ___ Tetanus ___ Metal ___ Dyes ___
Iodine ___ Aspirin ___ Codeine ___ Morphine ___ Adhesive Tape ___ Arthritis Medicine ___
Foods (please list): _____________________________________________________________________
Others: ______________________________________________________________________________
Please explain allergic reaction: ___________________________________________________________
Do you currently use tobacco: Yes ___ No ___ Cigarettes ___ Pipe ___ Smokeless ___
Amount per day ________ Quit when? _____________
Do you drink alcohol: Beer ___ Liquor ___ Wine ___ Amount per day _______ Per week ________
What is your current occupation? _________________________________________________________
Has anyone in your family had:
High Blood Pressure ___ Heart Disease ___ Diabetes ___ Bleeding Problems ___ Lung disease ___
DVT(blood clot) ___ Cancer_____(if yes, what type) __________________________________
Have you recently had any of the following problems or symptoms:
Yes
No
Chest Pain
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Irregular Heart Beat
Fainting Spells
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Breathing difficulties
Cough
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Cough with blood
Numbness or tingling
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Dizziness
Headaches or migraines
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Vision Changes
Fever or chills
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Unexpected weight loss
Abdominal pain
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Nausea or vomiting
Diarrhea
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Bloody or black terry stools
Loss of control of bowels
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Difficulty starting urination
Pain or burning on urination
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Blood in urine
Loss of control of bladder
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Yes
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No
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Patient Signature:___________________________ Physician’s signature: _________________________
(I have reviewed this information with the patient)
Ht ________________ Wt ______________ Blood Pressure: _________/__________ Pulse ________