Please provide the following information. This information is important for our records and your health.
First Name (required)
Middle Name
Last Name (required)
Your Email (required)
Street Address
City/State
Zip Code
Telephone
Alternate Telephone
Social Security Number
Sex male female
Birthdate/Age
Primary Language
Race ---African AmericanAmerican IndianAsianBlackNative HawaiianPacific IslanderWhiteNot Specified
Ethnicity ---HispanicNon-Hispanic
Employer
Occupation
Work Address
Work Telephone
Which of the following medical conditions apply to you? Diabetes Blood Clots or Phlebitis Cancer Gout Heart Problems HIV Bleeding Disorders Hepatitis Asthma High Blood Pressure Immune Disorders Seizures Arthritis Circulation Problems Kidney Problems Stomach/GI Ulcers
Other Medical Conditions?
Are you Currently Taking Any Medications (Include Vitamins and Herbs)?
Have you Ever Experienced any Allergic Reactions or Adverse Effects from any of the Following? Penicillin Aspirin Sulfa Drugs Codeine Novocain Motrin Iodine Shellfish Egg White Lactose Latex Metal Tape
Other Allergic Reactions?
What Pharmacy Do you Use?
Please List Surgical Procedures and Dates
Do you Drink? no yes
Do you Smoke? no yes
Referring Doctor/Individual
Family Physician/Primary Care Doctor
PCP Telephone
Date Last Seen
Present Weight
Present Height
Shoe Size
Have You Ever Seen A Podiatrist? Where?
What are We Seeing You for Today? How Long have You had the Symptoms?
Napa Solano Foot & Ankle
Email: connect@nsfaa.com
Vallejo Office: 1460 North Camino Alto, Suite 101 Vallejo, CA 94589 Phone: (707) 644-4049 Fax: (707) 644-4687
Napa Office: 935 Trancas Street, Suite 2C Napa, CA Ph: (707) 259-0766 Fax: (707) 259-0183
