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New patient appointment
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Follow-up appointment
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RIGHT foot pain
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LEFT foot pain
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RIGHT and LEFT foot pain
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RIGHT ankle pain
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LEFT ankle pain
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RIGHT and LEFT ankle pain
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Nail discoloration
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Ingrowing toenail
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Nail injury
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Toe injury/discoloration
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Broken/ Fractured Bones
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Gangrene
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Wound/Ulceration
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Laceration
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Burn wounds
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Foreign body
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Nerve injury
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Soft tissue mass
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Achilles tendonitis
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Plantar fasciitis
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Other foot/ankle injuries
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Other foot/ankle deformities
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Cyst
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Joint dislocation
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Bone spurs
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Gout
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Flat feet/collapsed arches
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High arch feet
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Bunion/Hammertoes
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Charcot arthropathy
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Diabetic foot examination
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Plantar wart
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Diabetic routine care
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Foot/Ankle Injury
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Second opinion
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Surgery Consultation
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Other
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If Other, please explain
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Past Medical History
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Anemia
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Asthma
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COPD
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Sleep apnea
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Diabetes mellitus
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High blood pressure
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HIV/AIDS
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History of blood clot
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Stroke
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Osteoarthritis
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Seizure
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Gout
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Thyroid disorder
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GERD
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Kidney disease
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Liver disease
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Stomach ulcer
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Tuberculosis
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High Cholesterol
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Rheumatoid arthritis
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Peripheral vascular disease
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Heart disease
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Hepatitis
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Current smoker
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Former Smoker
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Cancer
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If Cancer, please specify what type of cancer
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If Other medical history, please write in below box
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Allergies
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If NO allergies, please click this one
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Adhesive tapes
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Aspirin
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Codeine
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Iodine
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Latex
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Local anesthetics
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Opioids
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Penicillin
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Shellfish
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Sulfa drugs
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If other, please let us know below
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Review of Systems
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Check all symptoms you experienced in last month.
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GENERAL: if no symptoms, click this one
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GENERAL
• • •
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HEENT: if no symptoms, click this one
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HEENT
• • •
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NECK: if no symptoms, click this one
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NECK
• • •
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SKIN: if no symptoms, click this one
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SKIN
• • •
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RESPIRATORY: if no symptoms, click this one
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RESPIRATORY
• • •
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CARDIOVASCULAR: if no symptoms, click this one
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CARDIOVASCULAR
• • •
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MUSCULOSKELETAL: if no symptoms, click this one
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MUSCULOSKELETAL
• • •
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ENDOCRINE: if no symptoms, click this one
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ENDOCRINE
• • •
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GENITOURINARY: if no symptoms, click this one
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GENITOURINARY
• • •
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NEUROLOGICAL: if no symptoms, click this one
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NEUROLOGICAL
• • •
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HEMATOLOGY: if no symptoms, click this one
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HEMATOLOGY
• • •
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GASTROINTESTINAL: if no symptoms, click this one
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GASTROINTESTINAL
• • •
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PSYCHIATRIC: if no symptoms, click this one
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PSYCHIATRIC
• • •
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Pertinent History
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Are you currently smoking cigarettes?
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If smoking cigarettes, how many cigarettes per day?
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If smoking cigarettes, how many years have you been smoking?
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Do you drink alcohol?
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If yes, choose
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Do you have any drug abuse history?
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If Yes, please name the drugs
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Do you use recreational drugs?
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If Yes, please name the drugs
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Are you currently pregnant?
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If you are currently pregnant, roughly how far are you?
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If you are post-partum, are you currently breastfeeding?
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If post-partum, did you have gestational diabetes?
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Past Surgical History
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Foot surgery
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Ankle surgery
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Joint replacement surgery
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Heart valve placement surgery
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Stent placement in heart
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Spine surgery
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Stent placement in lower extremity
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Abdominal surgery
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Hernia surgery
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Appendicitis
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Gall bladder surgery
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If Others, please let us know
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Family Medical History
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Please state Mother side medical history, if any (e.g. Diabetes, Heart disease, Cancer)
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Please state Father side medical history, if any (e.g. Diabetes, Heart disease, Cancer, etc)
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Additional HIPAA related questions
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May we discuss your medical condition with any member of your family?
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If you selected "Yes" above, please name the members allowed:
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May we phone, email, or send a text to you to confirm the appointments?
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May we leave messages on your answering machine at home or on your cell phone regarding the visits?
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Are we allowed to obtain medication records from your pharmacy for accurate documentation of your current medications?
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