PATIENT INITIAL HISTORY QUESTIONNAIRE
This is a collection of clinical data. The information entered here will be automatically collected in a spreadsheet for your reference; and this will be transmitted to our office to provide efficient individual patient care if you click SUBMIT at the bottom of the form. You may cancel this questionnaire and fill out a handwritten questionnaire prior to your visit.
Email address *
Patient's Last name
Last name
Your answer
Patient's First name
Your answer
DOB *
Patient's date of birth
MM
/
DD
/
YYYY
Gender *
Reason for visit: Which foot/leg/ankle? Right, Left, or both.
Reason for visit *
Primary problem
Required
Primary Care Physician
Who is your current family doctor?
Your answer
Referral
Who referred you to our office?
Your answer
History of the present illness (HPI) : Characteristics of the pain or problem *
ie, dull, sharp, aches all day, walking on glass, ankle swells and tight
Your answer
HPI: Pain Scale *
History of present illness: Severity
least
worst
HPI: Other symptoms
ie, worse first thing in the morning, pain at end of day, only when jogging
Your answer
HPI: Length of Time
How long has this problem been present
Your answer
HPI: What aggravates or alleviates the problem
ie, walking barefoot, standing, Mortin reliefs pain
Your answer
Pharmacy
Which pharmacy do you use? Name and street location - for electronic prescriptions
Your answer
Medications *
Are you taking any medications for this or OTHER problems?
Medications
List of all current medications with doses and frequency
Your answer
Allergies *
Do you have medication or drug allergies?
Medications Allergies
List medications with the adverse reaction experienced
Your answer
HPI: Environmental factors
Recent lifestyle changes
FHx: Mom
Family history
Mom
Cardiovascular disease
Diabetes
Hypertension
Cancer
Other
FHx: Dad
Family history
Dad
Cardiovascular disease
Diabetes
Hypertension
Cancer
Other
FHx: Sibling
Family history
Sibling
Cardiovascular disease
Diabetes
Hypertension
Cancer
Other
FHx: Other
Family history
Other relative
Cardiovascular disease
Diabetes
Hypertension
Cancer
Other
PMhx *
Past medical history
Required
Past Surgical or Major Medical Eventss
List past surgeries and major events, such as, hospitalization or rehab
Your answer
SHx: Tobacco use history *
Current, former quantity + #years
Current + high (1+ppd, 2+ servings/d, 7+ servings/ wk)
Current + low-med (<1ppd, <2 servings/d, <7 servings/wk)
Former use more than 6mo ago
No current or former use
Tobacco use
Alcohol use
Rx use (illicit, IV, or off-prescription)
Sexual activity unprotected
SHx: Current job + daily activities
What do you spend the majority of their time doing? Is it sedentary or active? Exposures involved?
Your answer
SHx: Physical activity
Daily average over 1 week
No physical activity
Marathon runner or equivalent
SHx: Diet
Any dietary restrictions? Adherence to a specific diet? Dietary concerns?
Your answer
SHx: Vaccines not current
Which are NOT up to date? Booster required
Last foot exams
Enter dates
Your answer
Imaging
Enter location of any imaging for this problem
Your answer
Recent labs
Enter dates
Your answer
Lab company
Where were you labs performed?
ROS: *
on going abnormalities/ medial problems
Required
Email
Patients email address to register for your electronic charting
Your answer
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