DR. BERNARD GOLDSTEIN, P.A.

13615 Bruce B. Downs Blvd., Suite 112

131 N. Moon, #6

38122 North Avenue
Tampa, Florida   33613 Brandon, Florida Zephyrhills, Florida
(813) 972-3338 | Fax:  (813) 977-9070 (813) 685-1354 (813) 782-1229

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MEDICAL HISTORY

PATIENTS NAME:

DATE:

FAMILY PHYSICIAN:

HOW DID YOU HEAR ABOUT THE OFFICE?

  

HEIGHT:

WEIGHT:

SHOE SIZE:

WHAT IS YOUR CHIEF FOOT COMPLAINT?

  

HOW LONG HAS THIS BEEN A PROBLEM?

ANY PREVIOUS TREATMENT?

  

FORMER FOOT DOCTOR:

LAST VISIT:

ANSWER YES OR NO

1.  ARE YOU IN GOOD HEALTH?

 YES NO

2.  ARE YOU NOW/HAVE YOU BEEN UNDER A PHYSICIAN'S CARE DURING THE PAST

TWO YEARS?

 YES NO    

3.  DO YOU SMOKE?

 YES NO (IF YES, HOW MANY PACKS A DAY?)

4.  DO YOU DRINK?

 YES NO (HOW MUCH AND HOW OFTEN?)

5.  DO YOU EXERCISE?

 YES NO (IF YES, WHAT TYPE?)
CHECK ANY OF THE FOLLOWING SURGERIES YOU HAVE HAD:

TONSILS APPENDIX GALLBLADDER HERNIA FOOT

INJURIES/FRACTURES FEMALE GASTRIC RECTAL

OTHERS
ARE YOU ALLERGIC TO ANY OF THE FOLLOWING?

PENICILLIN ASPIRIN CODEINE IODINE TAPE LOCAL

ANESTHETICS

 OTHER
CHECK ANY OF THE FOLLOWING:

DIABETES ULCERS CARDIAC PHLEBITIS TB

ARTHRITIS

 STROKE EPILEPSY ASTHMA GOUT

KIDNEY

 HEPATITIS LIVER BLOOD CLOTS HIV/AIDS

RHEUMATIC FEVER

 BLEEDING DISORDERS BACK PROBLEMS POOR CIRCULATION

NERVOUS DISORDER

 OTHER

FAMILY HISTORY (LIST ANY THAT APPLY) 

EXAMPLES:  DIABETES / GOUT / HEART PROBLEMS

MOTHER:

DECEASED/

CAUSE OF DEATH
   

FATHER:

DECEASED/

 CAUSE OF DEATH
   

BROTHER:

DECEASED/

CAUSE OF DEATH
   

SISTER:

DECEASED/

CAUSE OF DEATH
LIST ANY MEDICATIONS YOU ARE TAKING ON A REGULAR BASIS:
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