form – LoneStar Foot & Ankle Group

PAST MEDICAL HISTORY

First Name Last Name HEENT RESPIRATORY NEUROLOGICAL CARDIOVASCULAR GASTROINTESTINAL HEMATOLOGY/CANCER URINARY/CANCER ENDOCRINE RHEUMATOLOGIC PSYCHIATRIC MUSCULOSKELETAL STD’s

PAST SURGICAL HISTORY

SURGERY REASON YEAR HOSPITAL

REVIEW OF SYSTEMS

CONSTITUTIONAL

Fever
Night Sweats
Weight Loss
Dizziness

EYES

Dry Eyes
Visual Disturbances
Irritation

GENITOURINARY

Urinary loss of control
Difficulty Urinating
Increased frequency
Blood in urine
Incomplete Emptying

CARDIOVASCULAR

Chest pain on exertion
Heavy chest
Tarry stools/ blood
Leg pain on exertion
Irregular heart beats

GASTROINTESTINAL

Abdominal pain
Vomiting
Change in Appetite
Sore throat
Diarrhea
Trouble Swallowing

RESPIRATORY

Cough
Wheezing
Shortness of Breath
Coughing up Blood
Sleep Apnea
Snoring
Fainting

NEUROLOGICAL

Loss of consciousness
Depression
Weakness
Numbness
Seizures
Dizziness
Restless legs
Memory loss
Migraines

INTEGUMENTARY

Changes in moles
Jaundice
Eczema
Rash
Dry skin
Growth/lesions

HEMATOLOGIC

Swollen Glands
Easy Bruising/Bleeding

ENDOCRINE

Fatigue
Increased Thirst
Increased Hunger

ALLERGIES

ALLERGY REACTION

MEDICATIONS

DRUG NAME STRENGTH FREQUENCY TAKEN

FAMILY HEALTH HISTORY

RELATION	ALIVE	AGE	SIGNIFICANT HEALTH PROBLEMS
Grandmother Maternal
Grandfather Maternal
Grandmother Paternal
Grandfather Paternal
Father
Mother
Brother/Sister
Other

SOCIAL HISTORY

Education	< 12th grade	High school	Associates	Bachelors	Masters	Doctorate
Caffeine
Alcohol
Tobacco
Drugs
Father
Mother
Brother/Sister
Other

Main reason for today’s visit? (please be specific)

Which extremity is bothering you today?

Right
Left
Both

History of present illness/injury

Check all that apply:
Dull
Throbbing
Sharp
Electrical
Shooting
Intermittent
Constant
Burning
Aching
Pins/needles
Worse in AM
Worse in PM
Rate your pain on below scale: RWhat makes the pain worse? What makes the pain better? What have you done for the problem? Have you had the problem before? Same area?