Name:    

Address: 

City:    

State:   

ZIP:     

Phone:   

FAX:     

Email:   

Briefly describe your foot problem in your own words, and list the name of your health insurance carrier or HMO/PPO, if applicable:

How long have you had this foot problem?

days weeks months years

Does your foot problem seem to be getting better, worse, or has it stayed the same?

better worse the same

If you are in pain, please describe the quality (burning, sharp, dull, etc.).

If you are in pain, please quantify the pain (on a scale from 1-10, 10 being the worst pain of your life).

1 2 3 4 5 6 7 8 9 10

If you are in pain, does the pain radiate to another part of your foot, ankle, leg, or back? Please describe.

What time of the day are your symptoms at their worst?

morning evening at night same all day long after prolonged standing after exercising

What, if anything, makes your foot feel better? Worse?

Have you received any treatment for this foot problem so far? Please describe.

Have you recently injured your foot in any way? If yes, please describe.

Please list all surgery you have had in the past 5 years.

Please list all prescription and non-prescription medications you are currently taking.

Please list any allergies that you have to medication.

If you have been hospitalized in the past 5 years, please list the dates and reasons for hospitalization (excluding childbirth without complications).

Please list all of your medical illnesses, if any (i.e. hypertension, diabetes, heart problems, stomach ulcers, etc.)