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Age and Sex
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Accompanied by
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Date Last Seen
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Foot wear INSIDE Home
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Foot wear OUTSIDE home
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Problem(and Location)
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Problem in patients words
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Onset (when did problem begin)
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Onset Comments
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Location of problem
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Location of problem comments
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Progress(new problem)
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Progress(0-100%)-f/u and new problems
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Severity of Pain(1-10)
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Severity Comments
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Severity of Pain in AM(1-10)
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Severity of Pain in PM(1-10)
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Duration(when do symptoms occur and how long)
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Duration Comments
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Aggravating factors
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Aggravating factors Comments
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Treatments
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Treatment
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Related Symptoms(what else is it affecting?)
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Other Symptoms comments
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Previously treated?
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What was done?
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Diagnostic testing?
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