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Patient Information
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Referred by
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Primary Care Physician
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Primary Care Physician Phone
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Pharmacy
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Pharmacy Phone
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Pharmacy Address
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Patient Employer / School Information
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Employer / School Phone
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Occupation
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Employer / School Address (City, State & Zip)
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Employer / School Phone
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Responsible Party
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Billing Name (If other that patient)
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Phone Number
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Relation to Patient
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Address, City, State & Zip:
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Reason for Visit
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What brings you to the office today?
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Describe any prev treatment & care you have rcvd
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Pain Assessment
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Indicate your level of pain on a scale of 1-10
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Check the symptoms that best describe your prob
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Other symptoms
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Are your symptoms getting
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What improves your symptoms?
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Addl Info / Improves your symptoms
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What makes your symptoms Worse?
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Other Symptoms
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Podiatry
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Do you Current or have you ever worn orthotics?
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Do you have any of the following?
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First steps out of bed in the morning painful?
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Does your foot pain limit your desired activity?
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If so, please describe:
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Have you ever had any other foot problem?
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Lifestyle Factors
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Weight
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Height
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Have you ever smoked?
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Number of Years
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# Packs / Day
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Do you smoke now?
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# Packs / Day
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Do you use recreational drugs?
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Types?
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# Times / Week
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How much alcohol do you drink / per week?
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How often do you exercise? # Times / Week
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How many hours a day do you stand? # of hours
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What type of shoes do you wear?
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Other Shoes
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What is your shoe size?
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Hospitalizations & Surgeries
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Reason
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Date
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Reason
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Date
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Current Medications
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Are you currently taking any blood thinners?
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What medications are you currently taking?
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Name
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Dosage
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Frequency
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Name
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Dosage
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Frequency
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Name
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Dosage
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Frequency
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Name
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Dosage
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Frequency
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Allergies
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Are you allergic to any of the following?
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Do you have any other allergies?
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Name
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Reaction
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Name
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Reaction
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Past Medical History
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Have you ever had any of the following?
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Family History
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Anyone in your family had any of the conditions
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Details
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Woman Only
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Are you pregnant?
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Are you breastfeeding?
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