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Preferred Contact
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Message information - Cell Phone
• • •
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Social History
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Smoking status
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Cigarettes smoked per day - Current
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Alcohol intake frequency
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Number of alcoholic drinks per week
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Recreational Drug use
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Recreational Drug list
• • •
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Other drugs
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Exercise
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Past Medical History
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Past and current medical conditions
• • •
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Others please specify
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Bleeding / Bruising
• • •
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Other conditions treated for
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Over the counter inserts
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Surgery or invasive procedure confirmation
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Surgeries or procedures
• • •
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Others please specify
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Custom Orthotics / Inserts
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Drug allergies confirmation
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Drug Allergies
• • •
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Others please specify
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Family Medical History Condition List
• • •
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Family history other
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Arthritis
• • •
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Diabetes Mellitus type I
• • •
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Diabetes Mellitus type II
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Family history reviewed - No changes
• • •
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Family history unknown
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Heart Disease
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Hypertension
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Peripheral Neuropathy
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Peripheral Vascular Disease
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None
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Others/not listed
• • •
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Pharmacy
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Pharmacy Name
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Pharmacy Address
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Release of Information
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Medical Contact Permission
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Release Of Information
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First individual's phone number
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Relationship to first individual
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Release of information - Additional Comments
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