DEPARTMENT OF PODIATRIC MEDICINE AND SURGERY
2
Where is your pain? DEPARTMENT OF PODIATRIC MEDICINE AND SURGERY We want to thank you for choosing to be seen in the Department of Podiatric Medicine. To better serve you, would you take time to fill out the following information? Thank you! WHICH DOCTOR OR CLINIC IS REFERRING YOU: ________________________________ Please describe your main problem today: __________________________________________________ Pain is: ___Burning ___Sharp ___Throbbing ___Dull ___Aching Pain severity: 1 2 3 4 5 6 7 8 9 10 (1=slight 10= most severe) What makes the problem worse? _______________________________________________________ What makes the problem better?________________________________________________________ If any injury, what caused the injury? Date _______________________________________________ Have you had any previous treatment? ___________________________________________________ Social History Age_____ Height___’___” Weight____ Shoe Size_____ Do you smoke? ___No ___Yes ____(pkg/day) Occupation: ________________________________________________________________________ Marital status: ____Single ___Married ___Widow Are you pregnant? ______________________ Do you use: ___Alcohol ___ Coffee Other: _____________________________________________ Past Medical History: Place an X in the blocks that apply to you. ___Asthma __Diabetes ___Heart Disease ___Stroke ___High blood pressure ___IBS ___Bleeding disorder ___ Arthritis ___Sickle Cell Anemia ___Hepatitis __Thyroid Disorder ___High Cholesterol ___Blood Clot ___Fibromyalgia ___ Depression ___Psoriasis Other: ____________________________________________________________________________ Allergies:_______________________________________________________________________________ Past Surgical History: (Type and date): ____________________________________________________ Family Medical History: Does any member of your immediate family have any of the following? ___Diabetes ___Stroke ___Heart Disease ___High Blood pressure ___Bleeding disorder ___Problem with anesthesia ___Cancer Other: _____________________________________________ Review of Systems: Place an X in the blocks that apply to you. Constitutional : ___Fever ___Fatigue ___Night sweats ___Anxiety Nervous: ___Numbness ___Headaches ___Spine disease ___Paralysis ___Dizziness ___Seizures ___Confusion ___Muscle Jerking ___Weakness Cardiovascular: ___Chest pain ___Rapid heartbeat ___Varicose Veins ___Feet swelling ___Heart problems ___Leg pain with walking __Shortness of breath Integumentary: ___Itching ___Ulcerations ___Moles ___Discolorations ___Skin rash ___Skin cancer ___Deformed nails Other:_______________________________________________ Musculoskeletal: ___Stiffness ___Fractures ___Sprains ___Sciatica ___Bunion ___Hammertoes ___Heel spur ___Knee pain ___Low back pain ___Long leg ___Shin splints ___Corrective shoes as a child ___Clubfoot Hematological: ___Anemia ___Take Coumadin/Aspirin/Plavix Gastrointestinal: ___Nausea/vomiting ___Constipation ___Diarrhea ___Heartburn ___Stomach ulcers ___Rectal bleeding ___Abdominal pain ___Change in bowel habits RT LEFT LEFT RT
Transcript of DEPARTMENT OF PODIATRIC MEDICINE AND SURGERY
Whereis yourpain?
DEPARTMENT OF PODIATRIC MEDICINE AN
We want to thank you for choosing to be seen in the Departmenyou, would you take time to fill out the following information? Tha
WHICH DOCTOR OR CLINIC IS REFERRING YOU: __
Please describe your main problem today: __________________Pain is: ___Burning ___Sharp ___Throbbing ___DullPain severity: 1 2 3 4 5 6 7 8 9 10 (1=slight 10= mWhat makes the problem worse? _______________________What makes the problem better?________________________If any injury, what caused the injury? Date _______________Have you had any previous treatment? ___________________
Social History Age_____ Height___’___” WeighDo you smoke? ___No ___Yes ____(pkg/day)Occupation:________________________________________Marital status: ____Single ___Married ___Widow Are yoDo you use: ___Alcohol ___ Coffee Other: _____________
Past Medical History: Place an X in the blocks that apply to you.___Asthma __Diabetes ___Heart Disease ___Stroke ___Hi___Bleeding disorder ___ Arthritis ___Sickle Cell Anemia ____High Cholesterol ___Blood Clot ___Fibromyalgia ___ DOther: ____________________________________________
Allergies:_______________________________________________
Past Surgical History: (Type and date): ____________________
Family Medical History: Does any member of your immediate f___Diabetes ___Stroke ___Heart Disease ___High B___Problem with anesthesia ___Cancer Other:_____________
Review of Systems: Place an X in the blocks that apply to you.Constitutional: ___Fever ___Fatigue ___Night sweats ___AnNervous: ___Numbness ___Headaches ___Spine disease ____Confusion ___Muscle Jerking ___WeaknessCardiovascular: ___Chest pain ___Rapid heartbeat ___Var___Heart problems ___Leg pain with walking __Shortness of
Integumentary: ___Itching ___Ulcerations ___Moles ______Skin cancer ___Deformed nails Other:_______________Musculoskeletal: ___Stiffness ___Fractures ___Sprains ____Hammertoes ___Heel spur ___Knee pain ___Low back___Shin splints ___Corrective shoes as a child ___ClubfootHematological: ___Anemia ___Take Coumadin/Aspirin/PlavGastrointestinal: ___Nausea/vomiting ___Constipation ______Stomach ulcers ___Rectal bleeding ___Abdominal pain
D SURG
t of Podiatnk you!
________
____________Achingost severe
____________________________________
t____ Sh
_________u pregnant_________
gh blood pr__Hepatitiepression_________
_________
_________
amily havelood pres_________
xiety__Paralysi
icose VeinsbreathDiscolorati___________Sciaticapain ___
ixDiarrhea___Chang
RT
ERY
ric Medicine. To better serve
______________________
_______________________
)____________________________________________________________________________________________
oe Size_____
_______________________? _____________________________________________
essure ___IBSs __Thyroid Disorder___Psoriasis_______________________
_______________________
_______________________
any of the following?sure ___Bleeding disorde_______________________
s ___Dizziness ___Seizure
___Feet swelling
ons ___Skin rash__________________________Bunion
Long leg
___Heartburne in bowel habits
LEFT LEFT
r
s
RT
FOR PHYSICIAN USE ONLY:
PCP: _________________________________________________________________________LAST VISIT:__________________________________________________________________MEDICATIONS: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
OTHER:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________
