194 Woodland Drive
Pearisburg, VA 24134
Phone (540) 921-2202
Fax (540) 921-2149
Last Name:______________________ MI___ First Name:________________________
I Preferred Name: ________________________________________________________
Date of Birth: ___/___/_____ Social Security Number: _____-____-_____
Sex: M / F Age:____ Weight_____lbs Height___ft___in Shoe Size____
Marital Status: [ ] Single [ ] Married [ ] Widowed [ ] Divorced
Family Doctor:______________________ Doctor’s Phone Number: (____) ____-______
Please Provide Your Preferred Pharmacy: ______________________________________
Employer: _______________________ Occupation:_________________________
Why Are You Being Seen Today? (Describe Your Foot Problem):___________________
_______________________________________________________________________
_______________________________________________________________________
Whom May We Thank For Referring You: ____________________________________
Address:_________________________________________________________________
_________________________________________________________________
City:_______________________ State:_____________________ Zip:______________
Home Phone: (____) ____-_____ Cell Phone: (____) ____-_____
Email: __________________________________________________________________
The Best Time to Contact Me Is: _________________________ [ ] AM [ ] PM
I Prefer to be contacted on/by [ ] Home Phone [ ] Cell Phone [ ] E-Mail
If you selected your Cell Phone how do you prefer to be contacted [ ] Call [ ] Text

Patient Name:__________________________________ DOB:__________
Last Name:______________________ MI___ First Name:________________________
Home Phone: (____) ____-_____ Cell Phone: (____) ____-_____
Address:_________________________________________________________________
_________________________________________________________________
City:_______________________ State:_____________________ Zip:______________
Relationship to Patient: [ ] Self [ ] Spouse [ ] Parent [ ] Other
If Self please move to the next section
If Other please specify:_____________________________________________________
Last Name:______________________ MI___ First Name:________________________
Date of Birth: ___/___/_____ Social Security Number: _____-____-_____
Address:_________________________________________________________________
_________________________________________________________________
City:_______________________ State:_____________________ Zip:______________
Home Phone: (____) ____-_____ Cell Phone: (____) ____-_____
Email: __________________________________________________________________
Employer: _______________________ Occupation: _________________________
Who Provides Your Insurance: [ ] Self [ ] Spouse [ ] Parent [ ] Responsible Party
If Self or Same as Responsible Party please move to the next section

Patient Name:__________________________________ DOB:__________
Last Name:______________________ MI___ First Name:________________________
Date of Birth: ___/___/_____ Social Security Number: _____-____-_____
Address:_________________________________________________________________
_________________________________________________________________
City:_______________________ State:_____________________ Zip:______________
Employer: _______________________ Occupation: _________________________
Do you or have you ever been treated for: (Please Check ALL That Apply)
[ ] Stroke
[ ] Phlebitis
[ ] Heart Attack
[ ] Vascular Disease
[ ] High Blood Pressure
[ ] A Heart Condition
[ ] Anemia
[ ] Diabetes
[ ] Gout
[ ] Sciatica
[ ] Poor Circulation
[ ] Kidney Disease
[ ] Osteoporosis
[ ] Lyme’s Disease
[ ]
Eyes: Glaucoma/manicular deg.
[ ] Keloid/ Thick Scar
[ ] Alzheimer’s
[ ] Rheumatic Fever
[ ] Arthritis
[ ] Epilepsy
[ ] Asthma
[ ] Hepatitis
[ ] Headaches
[ ] Nerve Disorder
[ ] Lung Disease
[ ] Liver Disease
[ ] Hearing/ Ear Disorder
[ ] Psychiatric Disorder
[ ] Tuberculosis
[ ] Thyroid Problem
[ ] Dark Urine
[ ] Cancer
[ ] Chronic Lt. Stool
[ ] Stomach Ulcer
[ ] Unexplained Weight Loss
[ ] HIV/AIDS
Others:_________________________________________________________________
Do you have vascular grafts? (if yes explain below)
Do you have joint implants? (if yes explain below)
Do you have replacement heart valves?
Are you now under active Chemo Therapy?
Have you had any other serious illness? (list below)
Have you ever been hospitalized or been under 24 hour medical care?
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] Yes
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
[ ] No
I Had Surgery For: On Date of: With Complications of:
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________

Patient Name:__________________________________ DOB:__________
Please list the relationship of family members who have had:
Diabetes:____________________________ Foot Problems:______________________
Arthritis:____________________________ Heart Attack:_______________________
Stroke:______________________________ High Blood Pressure:_________________
Cancer:_____________________________ Birth Defects:_______________________
Number of past child births_____ Are you currently Pregnant? [ ] Yes [ ] No
Are you slow to heal after cuts? [ ] Yes [ ] No
Any abnormal bruising, bleeding, or cuts? [ ] Yes [ ] No
Do you smoke now?
Did you ever smoke?
[ ] Yes [ ] No Packs/ Day ___ Years__
[ ] Yes [ ] No Packs/ Day ___ Years__
If you quit when did you do so? _____________________________________________
Do you consume alcoholic beverages? Circle one: None Rarely Moderately Daily Quit
Do you consume Recreational Drugs? Circle one: None Rarely Moderately Daily Quit
Are you currently taking any medications? [ ] Yes [ ] No If yes please list below
Medications: Frequency: For Treatment Of:
If you need more space to list your medications write on the back or ask the receptionist for paper.
Are you currently taking your medications as prescribed [ ] Yes [ ] No
Do you have any allergies with a history of skin reaction or other outward reaction or sickness following an injection, oral, or topical administration?
Check all that apply
Penicillin
Other antibiotics (list below)
Empirin / Tylenol (if yes, Circle)
Yes No Reaction to Medication
___ ___ ____________________________
___ ___ ____________________________
___ ___ ____________________________
Aspirin, Advil, Aleve, or Motrin (Circle) ___ ___ ____________________________
Celebrex, Bextra, Vioxx (Circle)
Other Pain Medicines (list below)
___ ___ ____________________________
___ ___ ____________________________
Morphine
Codeine
Demerol
Other Narcotics (list below)
Novocaine
___ ___ ____________________________
___ ___ ____________________________
___ ___ ____________________________
___ ___ ____________________________
___ ___ ____________________________

Patient Name:__________________________________ DOB:__________
Other anesthetics (list below)
Sulfa Drugs
Adhesive tape
Shrimp, Iodine, or Merthiolate
___ ___ ____________________________
___ ___ ____________________________
___ ___ ____________________________
___ ___ ____________________________
Others: _________________________________________________________________
________________________________________________________________________
________________________________________________________________________