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___________________________________
What type of problem are you having with your feet/legs?
When did your symptoms begin?
Have you seen another doctor for this problem?
Allergies to Medications
Please list:
Current Medications
Please list:
Flu Vaccinations
 Yes, I have had the vaccine this year
 I have been vaccinated in the past
 No, I do not get the flu vaccine
Past Medical History
Past Surgical History
Anemia
Joint Replacement
Surgical Procedure
Date__
Arthritis
Kidney Disorders
___________________________________
Bleeding Disorder
Lung Disease
___________________________________
Cancer
Multiple Sclerosis
___________________________________
Diabetes Type 1 Type 2
Murmur
Dialysis
Osteoporosis
Social History
Social History
Gout
Pacemaker
Heart Problems (Type___________)
Poor Circulation
Do you exercise?  Y  N
Heart Valve Replacement
Stroke
Do you drink alcohol?  Y  N
Hepatitis _____
Thyroid Condition
Do you smoke?
High Blood Pressure
Please list any other
Current Smoker Former Smoker Never
High Cholesterol
history:
History of depression?  Y  N
HIV
Review of Systems
Please check current symptoms even if controlled with medication.
GENERAL
CARDIOVASULAR
MUSCULOSKELETAL
FAMILY HISTORY
Nausea/Vomiting
High Blood Pressure
Foot Pain
Cancer
Fever
Murmur
Ankle Pain
Diabetes
Chills
Pacemaker
Toe Pain
High Blood Pressure
Dizziness
Mitralvalve Prolapse
Difficulty Walking
Stroke
Unusual Fatigue
A Fib
Weakness in Legs
Kidney Disease
HEAD, EYES, THROAT
Swelling in Legs
Foot Deformity
Chronic Cough
NEUROLOGICAL
Heel Pain
OTHER
Chronic Headaches
Stroke
Leg Cramping
Blurred Vision
Numbness in Feet
Swelling in Foot or Ankle
Trouble Swallowing
Tingling in Feet
Leg Pain when Walking
Blurred/Double Vision
Burning in Feet
Leg Pain at Rest
Poor Vision
SKIN
GASTROENTEROLOGY
RESPIRATORY
Wound/Sores
Blood in Urine or Stool
Shortness of Breath
Rash
Frequent Urination
Difficulty Breathing
Skin Cancer
Constipation
Asthma
Wart
Date:
Patient Name:
Date of Birth
:

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