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 ___
Medications
Include prescriptions, over the counter medications, and vitamins_______________________________________
___________________________________________________________________________________________
Pharmacy name_______________________________________Phone number____________________________
Allergies
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___
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