REVIEW OF SYSTEMS

Patient First Name

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Patient Last Name

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Date Of Birth

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Today’s Date

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REFERRAL SOURCE:

How did you hear about us?

Doctor:

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Hospital:

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Internet

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Insurance

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Family/Friend

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Newspaper

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Drive By

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Employee

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Phone Book

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HISTORY OF PRESENT ILLNESS/WHAT BRINGS YOU IN TODAY?

What is your specific foot/ankle problem?

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When did the problem begin?

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What improves the problem?

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Is the problem Painful?

Yes

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Is this from an injury?

Yes

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If yes, is it work related?

Yes

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If work related- Date of injury:

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What Foot/Ankle is involved?

Right

Left

Both

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Have you had similar problems in the past?

Yes

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How was the problem onset?

Sudden

Gradual

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The problem is worst:

At Rest

W/Activity

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What Aggravates the problem?

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Describe previous treatment:

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Describe the pain:

Sharp

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Dull

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Aching

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Throbbing

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Cramping

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Itching

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Popping

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Burning

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Tingling

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Clicking

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Shooting

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Stabbing

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Other:

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INDICATE AREA OF PAIN ON THE DIAGRAM BELOW

Left

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Right

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Have you had any of the following diagnostic studies for your current problem?

Diagnostic X-rays

Yes

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Date

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CT (computed tomography)

Yes

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Date

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MRI (magnetic resonance imaging)

Yes

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Date

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Epidural Steroid/ Facet Block injection

Yes

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Date

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EMG (electromyogram)/ NCV (nerve conduction velocity

Yes

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Date

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If you have a disc of any of these images please give them to the receptionist ASAP

Patient Name

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Date Of Birth

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Today’s Date

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REVIEW OF SYSTEMS

CONSTITUTIONAL

Recent Weight Changes

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Fever/Chills

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Nausea or Vomiting

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Fatigue

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Night Sweats

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PERIPHERAL VASCULAR

Temperature Changes in Feet

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Swelling in hands or feet

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Burning Sensation

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CrampinginfeetLegs

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INTEGUMENTARY

Bruising

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Callus/Corns

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Cracked Heels

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Drainage

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Ingrown Toenail

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Itching

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Keloids

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Nail Changes

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Nail Thickening

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Nail Discoloration

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Peeling

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Redness

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Ulcers

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Warts

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EYES

Eye Disease

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Wear Glasses

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Blurred or Double Vision

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EARS/NOSE/MOUTH/THROAT

Hearing Loss

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Nose Bleeds

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Sore Throat/Voice Change

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Sinus Problems

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Difficulty Swallowing

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RESPIRATORY

Shortness of Breath

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Chronic/Frequent Cough

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Wheezing

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CARDIOVASCULAR

Chest Pain

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Palpations

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Arrhythmia/Irregular Heartbeat

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GASTROINTESTINAL

Indigestion/Heartburn

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Diarrhea

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Blood in Stools

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Stomach Pains

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GENITOURINARY

Frequent Urination

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Painful Urination

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Kidney Stones

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Blood in Urine

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MUSKULOSKELATAL

Muscle Pain

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Joint Pain

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Joint Pain-Where:

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Stiffness/Swelling Joints

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Low Back Pain

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Trouble Walking

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Toe Pain

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Heel Pain

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Tendon Pain

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Bone Pain

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Atrophy

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Limited Range of Motion

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Deformity

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Swelling

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Arch Pain

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NEUROLOGICAL

Migraines

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Muscle Weakness

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Frequent Headaches

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Numbness/Tingling

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Dizzy Spells

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Paralysis/Tremors

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Burning

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PSYCHIATRIC

Anxiety

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Depression

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Insomnia

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Confusion

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Memory Loss

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ENDOCRINE

Hormonal Problem

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Excessive Thirst

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Excessive Urination

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Too Hot/Too Cold

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VITALS

For Office Use Only:

Weight

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Height

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Blood Pressure

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Temperature

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Pulse

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Respirations

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Shoe Size

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This document was reviewed by, Podiatric Assistant

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Date

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This document was reviewed by, D.P.M.

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Date

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Please sign your name in the area below

By submitting your signature, the parties agree that this agreement may be electronically signed. The parties agree that the electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

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