PATIENT INITIAL HISTORY QUESTIONNAIRE
This is a collection of clinical data. The information entered here will be automatically collected in a spreadsheet for your reference; and this will be transmitted to our office to provide efficient individual patient care if you click SUBMIT at the bottom of the form. You may cancel this questionnaire and fill out a handwritten questionnaire prior to your visit.
Sign in to Google to save your progress. Learn more
Email *
Patient's Last name *
Last name
Patient's  First name *
DOB *
Patient's date of birth
MM
/
DD
/
YYYY
Gender *
Reason for visit: Which toe/foot/leg/ankle? Right, Left, or both. *
Required
Reason for visit *
Primary problem
Required
Primary Care Physician
Who is your current family doctor?
Referral
Who referred you to our office?
History of the present illness (HPI) : Characteristics of the pain or problem *
ie, dull, sharp, aches all day, walking on glass, ankle swells and tight
HPI: Pain Scale *
History of present illness: Severity
least
worst
HPI: Other symptoms
ie, worse first thing in the morning, pain at end of day, only when jogging
HPI: Length  of Time
How long has this problem been present
HPI: What aggravates or alleviates the problem
ie, walking barefoot, standing, Mortin reliefs pain
Pharmacy *
Which pharmacy do you use? Name and street location - for electronic prescriptions
Medications *
Are you taking any medications for this or OTHER problems?
Medications
List of all current medications with doses and frequency
Allergies *
Do you have medication or drug allergies?
Medications Allergies
List medications with the adverse reaction experienced
HPI: Environmental factors
Recent lifestyle changes
FHx: Mom
Family history
Mom
Cardiovascular disease
Diabetes
Hypertension
Cancer
Other
Clear selection
FHx: Dad
Family history
Dad
Cardiovascular disease
Diabetes
Hypertension
Cancer
Other
Clear selection
FHx: Sibling
Family history
Sibling
Cardiovascular disease
Diabetes
Hypertension
Cancer
Other
Clear selection
FHx: Other
Family history
Other relative
Cardiovascular disease
Diabetes
Hypertension
Cancer
Other
Clear selection
PMhx *
Past medical history
Required
Past Surgical or Major Medical Eventss
List past surgeries and major events, such as, hospitalization or rehab
SHx: Tobacco use history *
Current, former quantity + #years
Current + high (1+ppd, 2+ servings/d, 7+ servings/ wk)
Current + low-med (<1ppd, <2 servings/d, <7 servings/wk)
Former use more than 6mo ago
No current or former use
Tobacco use
Alcohol use
Rx use (illicit, IV, or off-prescription)
Sexual activity unprotected
SHx: Alcohol Usage
How often do you have a drink containing alcohol?
SHx: Alcohol Usage
How many drinks containing alcohol do you have on a typical day you are drinking?
SHx: Alcohol Usage
How often do you have X drinks (5 for men; 4 for women & for men over age 65) or more drinks on one occasion?
SHx: Current job + daily activities
What do you spend the majority of their time doing? Is it sedentary or active? Exposures involved?
SHx: Sleep
Is lack of sleep disrupting your life? What’s the source of your sleep difficulties? How many hours/night do you get undisturbed sleep?
SHx: Physical activity
Daily average over 1 week
No physical activity
Marathon runner or equivalent
Clear selection
SHx: Physical activity
On average, how many days per week do you engage in moderate to strenuous exercises (like a brisk walk)?
Clear selection
SHx: Physical activity
On average, how many minutes per day do you exercise at this level?
SHx: What level is your Stress? *
minimal
extreme
SHx: Diet *
Any dietary restrictions? Adherence to a specific diet? Dietary concerns?  Normal, ADA, CVD, Keto, Paleo, Vegetarian, Vegan, Plant-based, Weight-control, Renal
SHx: Vaccines not current *
Which are NOT up to date? Booster required
Required
 Last foot exams
Enter dates
 Imaging
Enter location of any imaging for this problem
Recent labs
Enter dates
Lab company
Where were you labs performed?
ROS: *
on going abnormalities/ medial problems
Required
Email
Patients email address to register for your electronic charting
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms