Thefootcenter.org

THE FOOT CENTER, INC.
PATIENT RECORD ( 2010 ) Account #__________ TODAYS DATE_____________
PLEASE FILL OUT COMPLETELY
Location: Richmond / Chester / Colonial Heights / Kilmarnock
Dr. William Eng / Dr. Noel Patel
Patients full name:
Last________________________First_________________Middle__________________
Address: _________________________________________________________________
Patient SS Number:___________________________ Sex M F
Date of Birth______________________
What is your height? What is your weight? What is your Shoe size?
________________ ________________ ___________ Primary Phone Contact Number:______________________________
E-Mail ___________________________ Confirm Appointments by PHONE or E-MAIL?
Name of Spouse _____________________________________
Name and Relationship of Emergency Contact
________________________________________________ Phone number of Emergency Contact ___________________________________________
Pharmacy Name and Number ___________________________________________________
Name of Family Physician_________________________
Date last seen: __________________ Phone______________________________
Fax______________________________________
Address___________________________________
_________________________________________ SIGNATURE OF RESPONSIBLE PARTY DATE
Please describe what brings you to the office today?
______________________________________________________________________________________ ____________________________________________________________________________________ How would you describe your pain on a scale of 1 to 10? ________
(1 being no pain and 10 being worst pain) Describe your pain.
Sharp Aching Throbbing Shooting Electrical sensation Location of pain or primary complaint:
Lower Leg Ankle Achilles Tendon Heel Midfoot Arch Forefoot Sole of Foot Ball of Foot Top of Foot Big Toe Lesser Toes Toenails How long has your problems been present?
Onset of condition or injury:
Gradual onset over time Sudden onset from activity or injury Course/progression of condition:
Severe Worsening Moderate Worsening Mild Worsening Steady / Unchanging Mild Improvement Moderate Improvement Considerable/Good Improvement Pain / condition aggravated by:
Any weight bearing Standing Walking Running Exercise Bending Stooping Pressure to ball of foot Pressure from shoes Pressure from jumping Have you attempted any treatments to relieve your problem? YES / NO
Over the Counter Anti-Inflammatory Medication (Motrin, Aleve, Tylenol, Aspirin, etc.) In Home Whirlpool Stretching Trimming Out Toenail Yourself Applying Skin Cream Applying Topical Antibiotic Ointment ( triple antibiotic, bacitracin, Neosporin, ect. ) How much improvement and relief have you achieved with previous treatments?
Mild Improvement Moderate Improvement Considerable Improvement What is your activity level at work:
Considerable Movement/Walking Retired Heavy Lifting Past medical history: YES / NO
Hypertention/High Blood Pressure HIV/AIDS Hepatitis Heart Attack/MI Insulin Dependent Diabetes Non Insulin Dependent Diabetes Gastrointestinal - Do you have: YES / NO
Hematological -Do you have: YES / NO
Hematological - Have you been anticoagulant with any of the following blood thinners? YES / NO
Endocrine - Do you have: YES / NO
Musculoskeletal - Do you have: YES / NO
Musculoskeletal - Do you have any of the following joint replacements/prosthesis: YES / NO
Date of joint replacement:
___________________________________________________________ Immunology - Do you have: YES / NO
Past medical history – injuries/trauma YES / NO
__________________________________________________________________________________ Have you had any of the following foot surgeries: YES / NO
Please list approximate month and year of any surgery listed above:
_______________________________________________________________________________ Past Surgical History: Have you had any of the following surgeries? YES / NO
Heart Valve Repair/Replacement Appendectomy Medications - please list medications (including aspirin) currently taking:
______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Are You pregnant? YES / NO
If yes, when are you due? _________________ Allergies - Do you have allergies to any of the following: YES / NO
Drug allergies Penicillin Sulfa Erythromycin Iodine Local anesthetics no known allergies
Other allergies to medications - please list:
_______________________________________________________________________________ Do you have any food allergies - if so, please list:
_______________________________________________________________________________ Do you have any allergies to plants - if so, please list:
_______________________________________________________________________

Source: http://thefootcenter.org/images/New_Patient_H_P_SHORT_FORM_2010.pdf