|
Weight(lbs)
|
Height(Inches)
|
|
Women's Shoe size
|
Men's Shoe size
|
|
Past Medical History
• • •
|
Past Medical History- Other
|
|
Past Surgical History
• • •
|
Surgical History- Other
|
|
Family History
• • •
|
Family History Comments
|
|
Occupation
|
weightbearing status for pain?
• • •
|
|
Smoker
|
Comments
|
|
Alcohol
|
Comments
|
|
Marital Status
• • •
|
|
|
Living Arrangements
• • •
|
Other scenarios
|
|
Patient's diet
|
Comments
|
