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Preferred Method of Communication
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Email
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Marital Status
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Last Visit to Primary Care Physician
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Weight
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Height
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Occupation
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Employer
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Referred by
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Prior Podiatrist
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COVID-19 SCREENING
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Do you feel sick today with flu-like symptoms?
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Do you have a cough or shortness of breath?
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Do you have a sore throat or loss of smell & taste?
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Have you been around anyone else with COVID19 symptoms in the last 14 days?
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Are you living with anyone who is sick with COVID-19?
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Have you tested postive for COVID19 in the last 14 days?
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Primary Care Physician
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PCP Phone Number
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Do you have or have you had any of the following conditions?
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Kidney Disease
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High arches
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Heart Disease
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Flat feet
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Hypertension
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Bunions
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Hyperlipidemia
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Hammer toes
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Stroke
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Gout
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Circulatory problems (leg cramps, blood clots)
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Bursitis
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Lung conditions
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Warts
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Liver disease
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Toe nail problem
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Diabetes type 2 or type 1
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Back pain
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Thyroid disorders
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Hip pain
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Arthritis (osteoarthritis, rheumatoid, autoimmune disease)
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Knee pain
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Foot surgery
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Orthopedic surgery
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Unequal limb length
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Fractures (foot, leg)
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Raynaud's cold sensitivity
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Cancer
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Asthma
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Skin conditions (keloid formation, psoriasis, eczema)
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Nervous system disorders (anxiety, mental disorders, autoimmune)
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Weight issues, eating disorders
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Do you participate in any sports or recreational activities?
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If yes, which ones?
• • •
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List of any medical conditions not mentioned above
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List any prior surgeries
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Do you or have you smoked?
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If yes, how often?
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Do you or have you drank alcohol?
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If yes, how often?
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Pharmacy Information for Electronic Prescriptions
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Pharmacy Name
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Phone Number
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Address (cross/street)
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City
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State
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Zip Code
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Chief Complaint (Reason for Visit)
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