Patient Name (required)

Address (required)

Birthday (required)

Reason for Today's Visit (required)

Family Physician (required)

Occupation

Your Email (required)

Past Medical History (Please check the appropriate boxes)AnemiaArthritisAutoimmune DiseaseBleeding disordersCancerCellulitisCongestive heart failureDeep vein thrombosisDiabetesFracture historyFungal InfectionsGoutHeart DiseaseHigh cholesterolHigh blood pressureGastrointestinal disordersKidney diseaseLiver diseaseNeuropathyOsteaporosisPeripheral vascular diseasePoor circulationPsoriasisSciatica / Back problemsSeizure disorderStrokeThyroid problemsVaricose veinsWarts

Please specify for if you have checked off the following: Autoimmune disease, cancer, diabetes, and fracture history

Current Medication

AllergiesNo know allergiesPenicillinSulfaIodineAdhesive / TapeLocal AnestheticsCortisonAspirin

Other Allergies

Please list any surgeries or hospitalizations

Family history
DiabetesCirculatory ProblemHeart DiseaseGoutHigh Blood Pressure

Do you smoke?
NoYes

if yes, how long?

Do you drink alcohol?
NoYes

Do you exercise regularly?
NoYes

PLEASE READ AND SIGN
The above information is correct to the best of my knowledge. I understand that throughout my treatment at the Kingston Foot and Ankle Clinic I am responsible for notifying the Chiropodist of any and all updates to the information listed above. I give permission to the Kingston Foot and Ankle Clinic to use pictures of my lower extremity as an educational tool in videos and/or pamphlets. I understand that my identity will not be disclosed to the public in these pictures. No personal/medical information will be released to third parties without prior verbal or written consent. I consent to the assessment and/or treatment by the Chiropodist.