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Patient Portal
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(773) 941-4040
Patient Resources
Patient Portal
New Patient Forms
Articles
Insurance FAQ’s
Request an Appointment
(773) 941-4040
Meet the Team
COMMON CONDITIONS
Athletic Sports Injuries
Bunions
Diabetic Foot Care
Edema
Flat Feet
Foot & Ankle Fractures
Gout
Hammertoes
Ingrown Toenails
Tendonitis
TOENAIL FUNGUS
Warts
CONTACT
Meet the Team
COMMON CONDITIONS
Athletic Sports Injuries
Bunions
Diabetic Foot Care
Edema
Flat Feet
Foot & Ankle Fractures
Gout
Hammertoes
Ingrown Toenails
Tendonitis
TOENAIL FUNGUS
Warts
CONTACT
Search
Patient Information
Name
First
Last
Address
Street Address
Address Line 2
City
State
ZIP / Postal Code
Date of Birth
Birth Gender
Gender identity
Preferred Phone
Preferred Phone
cell
home
Alternate Phone
Email
Marital Status
Single
Married
Widow
Divorced
Separated
Employer
Job Title
How did you hear about us?
Emergency Contact
Relationship
Emergency Contact Phone
Alternate Phone
What is bothering you today?
Which foot?
Left
Right
Both
How many days/months/years has this been going on? How did this happen?
Write a number from 0 to 10—with 0 signifying no discomfort and 10 the highest level of pain—to rate your pain or discomfort over the last several days.
Is your pain constant?
Yes
No
What type of pain?
Sharp
Shooting
Throbbing
Aching
Burning
Constant
Intermittent
What have you done to treat it?
Nothing
Orthotic
Brace
Anti-inflammatory
Lotion/cream
Antibiotic
Changed shoe
Ice
Elevation
Other
Other
What makes your symptoms worse?
Did this happen while you were at work?
Yes
No
Is your employer aware?
Yes
No
Height (ex.5’10”)
Weight (lbs)
Shoe Size
Please complete all parts of this form. It is important to provide detailed and accurate answers to all questions.
Primary doctor’s name
Date last seen by primary
Pharmacy name & location
Medical History: Indicate your current/past conditions
No Conditions
AIDS/HIV
Anemia
Anesthesia Problems
Anxiety/Depression
Arthritis
Asthma
Autoimmune Disorder
Back Pain
Bleeding Disorder
Blood Clot/DVT
Cancer
Coronary Artery Disease
Diabetes: T1 or T2
Dialysis
Dyslipidemia
Edema
Ehlers Danlos Syndrome
Emphysema/COPD
Fibromyalgia
Foot Deformity
Gout
Headaches
Healing Problems
Heart Disease
Hepatitis
High Blood Pressure
Kidney Disease
Kidney Stones
Leg/Foot Ulcers
Liver Disease
Lung Disease
Malignant Hyperthermia
Organ Transplant
Osteoporosis
Other Heart Issues
Pacemaker
Peripheral Vascular Disease
Pneumonia
PTSD
Pulmonary Embolism
Raynaud’s Disease
Rheumatoid Arthritis
Seizures/Epilepsy
Stroke
Thyroid Problems
Varicose Veins
Social History
Exercise Level
none
Occasional
Moderate
Heavy
How many days per week?
1-2
3-4
5-7
Are you currently employed?
Yes
No
Retired
N/A
Occupation
Do you or have you ever smoked tobacco?
Never
Former Smoker
Current Smoker
Do you or have you ever used cannabis?
Yes
No
What is your level of alcohol consumption?
None
Occasional
Moderate
Heavy
How many days per week?
1-2
3-4
5-7
Do you use any illicit or recreational drugs?
Yes
No
What is your level of caffeine consumption?
None
Occasional
Moderate
Heavy
Medications
Do you consent to share your medication records with us?
Yes
No
N/A
If yes, please list Prescribed & Over the Counter medication
Allergies: Drugs & Reactions
None
Please name Allergies: Drugs & Reactions
Surgeries/Hospitalizations (Feet & All Others)
Ankle Surgery
Yes
No
Which Ankle
Left
Right
Foot Surgery
Yes
No
Which Foot
Left
Right
Type of Surgery & Date
Family History
AIDs/HIV
Mom
Dad
Alzheimer’s
Mom
Dad
Anemia
Mom
Dad
Anesthesia Problems
Mom
Dad
Arthritis
Mom
Dad
Asthma
Mom
Dad
Bleeding Disorder
Mom
Dad
Blood Clots
Mom
Dad
Cancer
Mom
Dad
Depression
Mom
Dad
Diabetes
Mom
Dad
Emphysema
Mom
Dad
Heart Disease
Mom
Dad
Heart Attack
Mom
Dad
High Blood Pressure
Mom
Dad
High Cholesterol
Mom
Dad
Kidney Disease
Mom
Dad
Neurological Disorder
Mom
Dad
Psychiatric Disorder
Mom
Dad
Raynaud’s Syndrome
Mom
Dad
Seizures
Mom
Dad
Stroke
Mom
Dad
Thyroid Disease
Mom
Dad
Ulcers: Foot/Leg
Mom
Dad
Other
Have you experienced any of these symptoms in the last few weeks?
None of these symptoms
None
General
fever
fatigue
chills
trouble sleeping
weakness
weight gain
weight loss
Head/Neck
dry eyes
irritation
vision change
eye disease/injury
wears glasses/contact lenses
ENT
difficulty hearing
ear pain
frequent nosebleed
nose problems
sinus problems
sore throat
snoring
bleeding gums
dry mouth
mouth ulcer
sinusitis
mouth breathing
ringing in ears
oral abnormalities
Cardiovascular
chest/arm pain on exertion
palpitation
shortness of breath: walking
shortness of breath: laying down
ankle swelling
light-headed on standing
Respiratory
cough
wheezing
shortness of breath
coughing up blood
sleep apnea
Gastrointestinal
abdominal pain
nausea
vomiting
constipation
black or tarry stools
frequent diarrhea
vomiting blood
dyspepsia
GERD
Genitourinary
urinary loss of control
difficulty urinating
increased urinary frequency
incomplete emptying
Musculoskeletal
muscle aches
muscle weakness
arthralgias/joint pain
back pain
swelling in extremity
neck pain
difficulty walking
cramps
osteoporosis
Skin
jaundice
rash
itching
dry skin
psoriasis
growth/lesions
non-healing areas
change in skin color
Neurologic
loss of consciousness
numbness
seizures
dizziness
frequent or severe headaches
migraines
restless legs
tremor
gait dysfunction
paralysis
Psychiatric
depression/anxiety
alcohol abuse
hallucinations
suicidal thoughts
mood swings
memory loss
dementia
delirium
Hematologic/Lymphatic
swollen glands
anemia
easy bruising
excessive bleeding
phlebitis
Allergic/Immunologic
runny nose
sinus pressure
itching
hives
frequent sneezing
Other
I certify that the above information is true and correct to the best of my knowledge. I give my permission to the doctor to administer and perform such procedures as may be deemed necessary in the diagnosis and/or treatment of my feet and/or ankles.
Name
Date
Meet the Team
COMMON CONDITIONS
Athletic Sports Injuries
Bunions
Diabetic Foot Care
Edema
Flat Feet
Foot & Ankle Fractures
Gout
Hammertoes
Ingrown Toenails
Tendonitis
TOENAIL FUNGUS
Warts
CONTACT
Patient Resources
Patient Portal
New Patient Forms
Articles
Insurance FAQ’s
Request an Appointment
(773) 941-4040
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