Swelling of Feet or Ankles..,... - Tri

Medical History
Chart
Date
Please Answei All Questlons
Are You In Good Health?
CiritOfrooO Dlseases (Measles, Mumps, Chlekenpox)
Famlly) . . t. .
Heart Disease (Personal or FamilY)...r
Dlabetes (Personal or
.
..;......
Hlgh Blood Pressure (Personal or Famlly)
Gout.
i r.r, r.
Stroke
Cancer. . .. ".
.t.
..
.. . ,
Arthrlils.
Ulcers
"t.....ir.....
Rheumatlc Fever
"
Gall Bladder, Llver or Kldney Trouble
......
Asthma
:........
Emphysema.....
Pneumonia......
Other Serious lllness:
Ghest Pain (Angina Pectorls)
Shortnesso|Breathwithwalkingorlylngdbwn.
Swelling of Feet or
Ankles..,...
.,
r.,.
Varicose Veins
Pain orCramps in legs while
walklng.
irrrr.
Nlght Cramps In legs or feet
Phteuttis (or blood clols).
Abnorma|BruisingorB|eeding....!......".....r
,,........,...:.'
f
L,
E,
Trauna
lr
any reactlon lrom:
Are You Allerglc to or had
Penlclllln, or other Antlblotlc
Morphlne,QodeineorDemero|..."......1".'1
""
Novocaln or other local anesthetlc '
r
i
Asplrln" .""'
Telanus..i'.'.
lodlne or M€rthlolata ' " "
Other Drug or Medlcailon
Any Foods
f Yes, how much?
Do You Smoke?
lf Yos, how much?
Do You Drink Alcohol?
lf Yes, What TYPe & When
Have You Had AnY Surgery?
Llst ALL Medlcatlons You Presently
tal<e
TRI.GITY PODIATRY GROUP
21
19 EL CAMINO REAL, OCEANSIDE, CA 92054
Welcome to our offico.,. Ih an( you for selecting our office to serve your foot and ankle care needs, We will strive to provide you with the very best medical
and surgical care, The following information is needed to better serve you, Thank you for taking the time to provide us with this information.
Home Phone:
Date:
PATIENT INFORMATION
Soc, Sec, #
r\ame:
Address:
State:_
City:
Birthdate:-
Marital
Status:-
Zip:-
Sex:
Email:
Age:-
Race:
Employer:
Occupation:
Business Address:
Business Phone:
Spouse Name:
Spouse Employer:
Business Address:
Business Phone:
Primary Physician:
LastVisit
Referring
Previous Podiatrist:
Emergency ConFbt
Phone:
Relation:
Person Responsible for Account:
Insured's Birthdate:
MF
Relation to Patient:
Soc, Sec, #:
Phone:
Address (lf different from patien
Insurance Company:
Additional Insurance?
Yes_ No_
lnsured's Birthdate:
Insured's Name
Soc. Sec. #:
Address (lf different from patient):
Insurance Company:
tD #:
Group #:
What is your presentfoot problem?
I hereby give permission to Dr. Thuen, Dr. Han, and/or associatos of Tri-City
Podiaky Group to examine, to photograph, to administer treatment, and to perform
such minor operative procedures as may be deemed necessary in the diagnosis and/or
treatment of my foot problbm.
SIGNATURE
DATE