FOOT & ANKLE SURGICAL GROUP		Douglas S. Stacey, D.P.M.
10561 Jeffreys Street		Gerald W. Torgesen, Jr., D.P.M.
Henderson, NV 89052		Philip J. Larsen, D.P.M.
Tel: 702-456-3668 • Fax: 702-456-6688

Medical History Form

(This form is CONFIDENTIAL)

Full Name: Date:

Date of Birth: Occupation:

Age: Shoe Size:

Name of Primary Care Physician:

Has he/she requested you to be seen in our office? Yes No

If not, who referred you?

Name of former Podiatrist:

Why did you see former Podiatrist?

Women only - Are you pregnant? Yes No If so, how many months?

What is your FOOT or ANKLE problem? PLEASE BE SPECIFIC.
Where does it hurt? How long has it been bothering you?
Is the pain sharp, dull, deep or superficial, stabbing or burning? Does it ache or tingle?
Is there any numbness? Have you had any previous treatment(s)?

List CURRENT MEDICATIONS - List dosage and why you are taking each medication.
Attach a separate list if neccessary.

1) 5)

2) 6)

3) 7)

4) 8)

List PREVIOUS SURGERY OR HOSPITALIZATIONS - Please indicate date, type & any complications.

Date of last: Physical Chest X-ray

EKG Tetanus

WHO IN YOUR FAMILY HAS:

Diabetes?

Heart Disease?

High Blood Pressure?

Cancer?

Stroke?

Other Family Related Medical Problems:

HAVE YOU EVER SMOKED? Yes No

DO YOU SMOKE NOW? Yes No When did you quit?

How many packs a day? For how many years?

DO YOU DRINK ALCOHOL? Yes No

How much per day? How much per week?

LIST ALL ALLERGIES TO MEDICATIONS:

CHECK ALL THAT APPLY

Constitution:

Good General Health Recent Weight Change Fever Fatigue

Eyes:

Eye disease or Injury Blurred vision Double vision

Glaucoma Wear glasses/contacts

Ears, nose, mouth, throat:

Hearing loss Tinnitus Ear aches Sinus problems

Nose bleeds Mouth sores Bleeding gums Sore throat

Voice change Swollen neck glands

Cardiovascular:

Hypertension Heart attack Chest pain Angina Palpitations

Respiratory:

Coughs Spitting up blood Shortness of breath Asthma

Gastrointestinal:

Loss of appetite or change in bowel movements Nausea Vomiting

Diarrhea History of rectal bleeding Abdominal pain Heartburn

History of stomach Duodenal ulcer

Musculoskeletal:

Joint pain Stiffness Muscle Weakness Muscle Cramps

Back pain Difficulty with walking

Integument/skin:

Rash Itching Change in skin color Change in nails

Neurological:

Frequent/recurring headaches Light headedness Dizziness Convulsions

Seizures Numbness Tingling sensations Tremors

Paralysis Stroke Head injury

Psychiatric:

Memory loss Nervousness Depression Insomnia

Endocrine:

Glandular problems Hormone problems Thyroid disease

Diabetes Heat intolerance Cold intolerance

Hematologic/Lymphatic:

Slow to heal after cuts Bleeding tendencies Anemia Phlebitis

Past transfusions Enlarged glands

Immunological:

Hepatitis A Hepatitis B Hepatitis C HIV Tuberculosis