Podiatric History

American Board of Podiatric Surgery

Fellow, American College of Foot Surgeons

Stephen R. Pittman, D.P.M., PA.

410 Christiana Medical Center

Newark, Delaware 19702

Podiatric History

Your chief complaint today?_____________________________________________________________________

Have you ever been to a podiatrist before?  Yes___ No___ If yes please enter name___________________________

Are your symptoms worse when wearing shoes?           Yes___ No ___

Do you spend more than 50% of your day standing?    Yes ___ No ___

Are your symptoms worse when standing/walking?    Yes ___ No ___


Include prescriptions, over the counter medications, and vitamins_______________________________________


Pharmacy name_______________________________________Phone number____________________________


Adhesive/tape___   Local Anesthetic___ Aspirin___Codeine___Latex___Novacaine___Sulfa___Penicillin___

Other________________________________________________________________No known allergies___

Medical History

Asthma___Lungs___Arthritis___Heart problems___Circulation problems___Blood clots___HIV/AIDS___

High blood pressure___Psoriasis___Thyroid___Fibromyalgia___Kidney problems___Liver disease/Hepatitis___

Joint replacement___Diabetes___Gout___Bleeding problems___Strokes/neurlogical disorders___Cancer___

Foot surgery___Other surgery___Back problems___Knee problems___Other____________________________

Since xrays may be required, are you (to your knowledge) pregnant?  Yes___No___

Print This Page Print This Page

  • Testimonials

    "Excellent experience!!! ...His facilities are warm and welcoming as is his personality....I definitely recommend Dr. Pittman for a podiatrist."
    D. Bear

    "Kind,intelligent podiatrist who shares a wealth of knowledge."
  • Follow Us


New Patient Forms

Important information from Dr. Pittman for you to print or download prior to your first visit.