Medical History Form
Manhattan Podiatry Associates, PC
Patient's Name *
Your answer
Today's Date *
MM
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DD
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YYYY
Have you been ill recently? *
If yes, explain: *
Your answer
Have you ever been hospitalized? *
If yes, explain: *
Your answer
Are you under the care of a Physician? *
If yes, explain:
Your answer
Have you ever had surgery? *
If yes, explain:
Your answer
Have you ever had surgery? *
If yes, explain:
Your answer
Do you smoke? *
If yes, how many packs per day?
Your answer
Do you drink alcohol? *
If yes, how much?
Your answer
Do you have asthma? *
If yes, when was the last episode?
Your answer
Rheumatic Fever? *
Heart Attack (Heart Disease or Murmur? *
If so, when? How many?
Your answer
High Blood Pressure? *
Anemia? *
Stroke? *
If yes, when?
Your answer
Jaundice? *
Diabetes? *
Epilepsy? *
If yes, type? When was the last episode?
Your answer
Tuberculosis? *
Venereal Disease? *
Are you taking medications now? *
If yes, list all medications you are currently taking
Prescription Vitamin and over-the-counter medications (examples: aspirin, antacids) and herbals (examples: ginseng, gingko). lnclude medications taken as needed (example:nitroglycerin). List name, dose, directions and times per day, date stopped, and any notes/ reasons for taking.
Your answer
Are you allergic to penicillin? *
Are you allergic to any other medications? List all
Your answer
Do you have prolonged bleeding? *
Are you Pregnant or Nursing? *
Name and Address of Physician *
Your answer
Physician's Phone number *
Your answer
Shoe Size *
Your answer
Patient Signature *
Your answer
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