Podiatry Associates of New Mexico, LTD
Healthcare Questionnaire
Patient Name: _____________________________________________________ DOB: ___________________
WHO REFERRED YOU YO OUR OFFICE? _________________________________________________
PRIMARY CARE PHYSICIAN: Name: __________________________________ Last Visit Date: _______
REFERRING PHYSICIAN: Name: ______________________________________ Last Visit Date: _______
PODIATRIC COMPLAINT:
Please indicate the reason for your visit today: ____________________________________________________
Please indicate the location of problem area: ______________________________________________
How long have you had this problem? __________________________________________________
Have you been seen by our physicians?
Yes [ ]
No [ ] If yes, when? ______________________________
Any other location besides Podiatry Associates of New Mexico? _____________________________________
AMBULATION: Circle any you use:
Crutches
Walker
Wheel Chair
Cane
Scooter
HOSPITALIZATION & MAJOR SURGERIES:
Have you been hospitalized or had any major surgeries in the past 12 months?
Yes [ ]
No [ ]
Any major hospitalizations prior to the last 12 months? (Joint Replacements, Heart Surgery, Stroke, etc.)
1. ______________________________ Date: _______ 4. ______________________________ Date: ______
2. ______________________________ Date: _______ 5. ______________________________ Date: ______
3. ______________________________ Date: _______ 6. ______________________________ Date: ______
PERSONAL HISTORY:
*Please Check All That Apply*
[ ] AIDS
[ ] Chronic Diarrhea
[ ] Headaches
[ ] Radiation/Chemo
[ ] Alcoholism
[ ] Circulatory Problems
[ ] Heart Disease
[ ] Respiratory Disease
[ ] Allergies/Hay Fever
[ ] Congestive Heart Failure
[ ] Hemophilia
[ ] Rheumatic Fever
[ ] Anemia
[ ] Hepatitis
[ ] High Blood Pressure
[ ] Sinus Problems
[ ] Arthritis
[ ] HIV
[ ] High Cholesterol
[ ] Skin Problems
[ ] Asthma
[ ] Depression
[ ] Kidney/Bladder Problems
[ ] Stroke
[ ] Back Problems
[ ] Diabetes
[ ] Liver Disease
[ ] Thyroid Problems
[ ] Bleeding Disorders
[ ] Ear Problems
[ ] Low Blood Pressure
[ ] Tuberculosis
[ ] Blood Clots/DVT
[ ] Eye Problems
[ ] Medical Implants
[ ] Varicose Veins
[ ] Blood Transfusion
[ ] Gallbladder Disease
[ ] Osteoporosis
[ ] Venereal Disease
[ ] Breast Disease
[ ] GERD/Hiatal Hernia
[ ] Pacemaker
[ ] Vertigo/Balance Loss
[ ] Cancer
[ ] GI Ulcers
[ ] Phlebitis
[ ] Welding Work
[ ] Chemical Dependency
[ ] Gynecological Problems
[ ] Psychiatric Care
[ ] Weight Loss
Current Height: __________ (Ft)
Current Weight: __________ (Lbs)
PANM Healthcare Questionnaire: Map: PANM Vault  Forms  Front Office Forms  Patient Demographics Form
Shoe Size: __________
Podiatry Associates of New Mexico, LTD
FAMILY HISTORY:
*Please Check All That Apply*
[ ] Heart Disease
Relationship: ________________________________________________
[ ] Cancer
Relationship: ________________________________________________
[ ] Diabetes
Relationship: ________________________________________________
[ ] Other: _______________ Relationship: ________________________________________________
SOCIAL HISTORY:
Do you participate in any exercise regimen on a regular basis? Yes [ ] No [ ]

If yes, what type and how often? _________________________________________________________
Do you currently smoke or chew tobacco? Yes [ ] No [ ]
… If no, any past tobacco use?
Yes [ ] No [ ]
Year stopped: _______ Years smoked: ______
… If yes, how many/much per day? _________________ Year started: _______
Do you consume any alcohol? Yes [ ] No [ ]

If yes, how much and how often? ________________________________________________________
MEDICATIONS:
Do you currently take oral contraceptives?
Yes [ ] No [ ]
Do you currently take vitamins and/or supplements?
Medicine Name: ________________________
Yes [ ] No [ ]
Please check if no medications are currently being taken. [ ] None
** Please list all prescribed and over the counter medications you are currently taking **
1. _________________________________________ 4. _______________________________________
2. _________________________________________ 5. _______________________________________
3. _________________________________________ 6. _______________________________________
Pharmacy Name: _____________________________________ Phone #: ______________________________
Pharmacy Address: _______________________________________________________________
ALLERGIES:
*Please Check All That Apply*
[ ] Iodine
[ ] Penicillin
[ ] Latex
[ ] Aspirin
[ ] Adhesive Tape
[ ] Demerol
[ ] Codeine
[ ] Seafood
[ ] Sulfa
[ ] Local Anesthetics (Novocain)
[ ] No Known Allergies
[ ] Other: ______________________________________________
CERTIFICATION:
I certify that the information provided above is true, correct, and complete to the best of my knowledge,
information, and belief.
_____________________________________________
___________________________________
Signature of Patient or Legal Guardian
Date Signed
_____________________________________________
Printed Name of Patient or Legal Guardian
PANM Healthcare Questionnaire: Map: PANM Vault  Forms  Front Office Forms  Patient Demographics Form