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Family Physician
__________________________________________________ Date of Last Medical Examination ________________________
Address
_______________________________________________________________________ Phone _____________________________
City ___________________________________ State ____________
What medications are your presently taking or use on occasion (if any), including prescription medications or over-the-counter medications and vitamins?
__________________________________________________________________________________________________________________
__________________________________________________________________________________________________________________
Are you allergic to any medications you know of? __________________________________________________________________________
| Are you being treated or have you been treated in the past for any of the following?
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| ________ High blood pressure (hypertension)
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________ Ulcers
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| ________ Low blood pressure
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________ Hiatal Hernia
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| ________ Diabetes
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________ Other G.I. problems
explain ___________________________
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| ________ Poor circulation
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________ Arthritis
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| ________ Phlebitis which leg(s) _________________
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________ Gout
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| ________ Glaucoma
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________ Stroke
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| ________ Heart murmurs
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________ Epilepsy
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| ________ Mitral valve prolapse
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________ Multiple sclerosis
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| ________ Angina
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________ Muscular dystrophy
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________ Other heart problems
explain ___________________________
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________ Neuropathy
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| ________ Emphysema
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________ Other neuromuscular problems
explain ___________________________
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| ________ Tuberculosis
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________ Psoriasis
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| ________ Asthma
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________ Cancer type? _______________________
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________ Other respiratory problems
explain ___________________________
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Describe any operations or
hospitalizations you have had and list the dates ___________________________________________________
________________________________________________________________________________________________________________
What problem(s) are you having with your feet or legs today? ______________________________________________________________
Other foot or leg problems you are concerned about? ____________________________________________________________________
Height _______________ Weight ________________ Shoe Size _______________ Shoe Type ___________________________________
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