Date* MM DD YYYY Name* What is your current foot problem?*Please input your primary foot problem above, additional foot problems can be listed below.How long has it bothered you?*Describe the quality of the pain* Burning Sharp Throbbing Aching N/A What is the severity of your pain/condition?*0 - No Pain1 - Very Slight Pain2 - Slight Pain3 - Mild Pain4 - Mild to Moderate Pain5 - Moderate6 - Moderate to Severe Pain7 - Severe Pain8 - Very Severe Pain9 - Extreme Pain10 - Worst Pain Imaginable*Please rank your pain above on a scale from 1-10, 10 being the worst painWhat signs and symptoms are associated with the condition?* Swelling of the foot and/or ankle Numbness/tingling Difficulty walking Redness Warmth Bruising Odor Drainage Cramping in the legs with walking Dry or cracked skin Itching Thickening of the nails Nausea/Vomiting/Fevers/Chills Cramping Joint Pain Joint Stiffness Muscle Weakness Other If other, please explain*When does the condition bother you?* Constantly (All of the time) Intermittently (Sometimes/comes and goes) In the morning During the day In the evening Never Other If other, please explain*Has the condition been treated?*YesNoIf yes, please explain*Is the condition getting better or worse?*BetterWorseSameWhat aggravates your condition?* Shoes Walking/Running Standing Exercise Other If other, please explain?*What factors modify/relieve the condition?* Rest Ice Elevation Stretching Heat Soaks Medication Wearing Shoes Removing Shoes Skin lotion/cream Other If other, please explain*Please list the medication that relieves the condition here*How did your condition present?* Acute (Sudden onset) Insidious (Gradual onset) Chronic (Slowly over time) Other If other, please explain?*Is there a history of injury?*YesNoIf yes, please explain*Is there a history of foot and/or ankle conditons in the past?*YesNoIf yes, please explain*PAST MEDICAL HISTORY(CHECK ALL THAT APPLY)* Diabetes Mellitus High blood pressure High Cholesterol Heart Disease Gout Stroke Cancer Epilepsy/Seizure disorder Kidney disease Liver Disease Circulation Disorder Asthma None List all other medical history:*Please list one per line. If none, please write none in the box above.MEDICATIONSList all current medications including over-the-counter medications, vitimans, and supplements:*Please list only one medication per line. If none, please write none in the box above.ALLERGIES(CHECK ALL THAT APPLY)* Penicillin Sulfa drugs Erythromycin Iodine/Shellfish Morphine Codeine Adhesive tape Latex Novocaine Aspirin None List any other allergies:*Please list one allergy per line. If none, please write none in the box above.PAST SURGICAL HISTORYList all surgeries and the date of procedure:*Please list only one surgery per line. If none, please write none in the box above.SOCIAL HISTORYMarital Status*SingleMarriedWidowedDivorcedDo you have children?*YesNoIf yes, how many?*1234567891010+Do you smoke?*YesNoAre you a former smoker?*YesNoIf yes, how many packs/day?*123455+If yes, how many packs/day did you used to smoke?*123455+How long have you smoked?*YearsWhen did you quit?*What Year?How long did you smoke?*In YearsDo you use alcohol?*NeverRarelySociallyModeratelyHeavilyDrinks/per day*1-23-56-87-910+Do you have a history of alcoholism?*YesNoIf yes, are you currently using alcohol?*YesNoHow long have you been sober?*Do you have a history of illegal drug use?*YesNoIf yes, which drug/drugs?*Are you currently using illegal drugs?*YesNoDo you have a history of addiction to prescription pain mediation?*YesNoIf yes, which drug/drugs?*Are you currently using prescription pain medication?*YesNoWhen did you last use prescription pain medication?*FAMILY HISTORY(CHECK ALL THAT APPLY)* Heart Disease Mother Heart Disease Father Diabetes Mother Diabetes Father Stroke Mother Stroke Father Cancer Mother Cancer Father High Blood Pressure Mother High Blood Pressure Father Kidney Disease Mother Kidney Disease Father Liver Disease Mother Liver Disease Father Arthritis Mother Arthritis Father Gout Mother Gout Father Peripheral Neuropathy Mother Peripheral Neuropathy Father N/A List all other family diseases:*Please list one per line. If none, please write none in the box above.REVIEW OF SYSTEMSCheck off all current conditions that applyCONSTITUTIONAL SYMPTOMS* Loss of appetite Weight loss Weight gain Fever Fatigue Not Applicable GASTROINTESTINAL* Nausea Vomiting Jaundice Diarrhea Not Applicable NEUROLOGICAL* Frequent or recurring headaches Light-headed or dizzy Seizures Numbness or tingling sensations Paralysis Not Applicable GENITOURINARY* Dialysis Kidney disease Kidney stones Not Applicable PSYCHIATRIC* Depression Insomnia Anxiety Not Applicable HEMATOLOGIC* Anemia Bleeding/Bruising tendencies Not Applicable EYES* Eye disease or injury Glaucoma Cataract Double vision/blurry vision Not Applicable MUSCULOSKELETAL* Joint Pain Joint stiffness Muscle weakness Not Applicable CARDIOVASCULAR* Chest pain Palpitations Shortness of breath Foot or leg swelling Not Applicable RESPIRATORY* Productive Cough Spitting up blood Wheezing Not Applicable DERMATOLOGIC* Rash Change in nails Non-healing wounds Dry and/or scaling skin Not Applicable ENDOCRINE* Excessive thirst Frequent urination Heat intolerance Cold intolerance Not Applicable Is there any other information you would like to share about your health?*If no, please write no in the box above.Height*in inchesWeight*lbsShoe Size*Please enter a number greater than or equal to 1.CommentsThis field is for validation purposes and should be left unchanged.