Patient History

Patient Number_______________________
Date_______________________________

Please print (set page margins to .5) and complete this form and either FAX it to us,
or bring it with you on your first visit with Dr. Gurvis.
Fax number 317-272-7508

Name ________________________________________________________SS#______________________________

Street _______________________________________City/State ___________________________ Zip____________

Phone____________________ Cell Phone_________________ Pager ________________ E-mail_______________

Birth Date_____________ Age__________ Sex_______ Weight_______ Height _________ Shoe Size __________

Check appropriate selection ___Minor _____ Single____ Married _____ Divorced ____Widowed _____Separated

If student, name of College/School_________________________________________ Full time____ Part time_____

Patient Employer__________________________________________________ work phone ___________________

Business address __________________________________ City/State_______________________ Zip__________

Spouses name _________________________________________________________________________________

Spouses employer_______________________________________________ work phone______________________

Business address________________________________ City/State________________________ Zip____________

Whom may we thank for referring you? ______________________________________________________________

Person and Phone to contact in an emergency ________________________________________________________

Who is responsible for this account _________________________________________________________________

Responsible Party Information for Minors

Name of Mother ______________________________________________Work Phone_________________________

Birthdate_________________________SS#___________________________________________________________

Employer_________________________________________ City/State___________________ Zip_______________

Name of Father_______________________________________Work Phone__________________________

Birthdate_________________________ SS# _____________________________________

Employer________________________________________City/State____________________ Zip______________

Patient Medical History

Physician______________________________ Office Phone ____________________Date of last exam__________

1. Are you under medical treatment now? __Yes __No ______________________________________________

2. Have you been hospitalized with serious illness or surgeries? ____ Yes ____ No

If yes, please describe_____________________________________________________________________

3. Are you Diabetic? ___ Yes ___ No
Please list allergies and reactions____________________
________________________________________________
________________________________________________
Please List All Medications ________________________
________________________________________________
________________________________________________
________________________________________________

Women Only:

1.Are you pregnant or
think you may be pregnant? __Yes__No

2. Are you nursing ? __Yes__No

3. Are you taking oral contraceptives? __Yes__No

4. Menopause? __Yes__No

Number of Pregnancies ________ Births__________

Past Medical History

Have you ever been treated for any of the following illnesses? (if yes, please check)

___ High Blood Pressure	___ Immunodeficiency Disease or HIV	___ Liver Disease
___ Heart Disease/Heart Attack	___ Diabetes	___ Rheumatic Fever
___ Stomach or Digestive Problems	___ Cancer	___ Neurological Problems
___ Emphysema/Bronchitis/Asthma	___ Arthritis	___ Circulation Problems
___ Depression	___ Ulcers	___ Thyroid Problems
___ Epilepsy/Seizures	___ Stroke	___ TB
___ Joint Replacement	___ Hepatitis
___ Heart Valves or Pacemaker	___ Phlebitis
Please comment on any illness checked above or write in other conditions __________________________________ ________________________________________________________________________________________________ ________________________________________________________________________________________________

Is your Tetanus up to date? ___Yes ___ No

Social History

Marital Status:	___ Married		___ Single		___ Divorced
Children:	___ No		___ Yes Number and ages ___________________
I Live:	___ Alone		___ With Someone
Alcohol Use____________	If so circle amount	1-6	6-12	12-18	18 + drinks per week
Tobacco Use ________	# of packs per day ______________________
Type of Work ___________________________________________________________________________________

Family History

Are there any diseases that run in your family (i.e. diabetes, rheumatoid arthritis, bleeding disorders or anesthetic complications such as malignant hyperthermia)? _______________________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________

Mother - Alive or Deceased
	If deceased, cause__________________________________________________________
Father - Alive or Deceased
	If deceased, cause__________________________________________________________

Review of Systems (Circle all that apply to you in the last two years)

Constitutional Symptoms (fever, weight loss, double vision, fatigue)
	explain____________________________________________________________________________
Eyes (double vision, blurring, glasses)
	explain____________________________________________________________________________
Ears, Nose, Throat and Mouth (deafness, sinusitis, hoarseness, vertigo)
	explain____________________________________________________________________________
Cardiovascular (chest pain, palpitations)
	explain____________________________________________________________________________
Respiratory (shortness of breath, asthma, cough)
	explain____________________________________________________________________________

*Review of Systems* (continued)

Stomach/Intestinal (loss of appetite, weight change, diarrhea, constipation, abdominal pain)
	explain____________________________________________________________________________
Urology (hesitancy, incontinence, burning urination, menstrual problems)
	explain____________________________________________________________________________
Muscular Skeletal (fracture, sprain, joint pain/swelling, arthritis)
	explain____________________________________________________________________________
Skin/Breast (rashes, lesions, scars)
	explain____________________________________________________________________________
Neuro (speech, swallowing problems, stroke, seizures, headaches)
	explain____________________________________________________________________________
Psych (depression, hallucinations, sleep disturbances)
	explain____________________________________________________________________________
Endocrine (growth/hair changes, excess thirst, decreased energy)
	explain____________________________________________________________________________
Hemotologic/Immunologic (easy bruising, blood clots, bleeding disorders)
	explain____________________________________________________________________________

Please answer the following questions to the best of your knowledge:

Complaint (in your own words, explain what you feel your foot problem is): ________________________________

______________________________________________________________________________________________

Result of an accident? ___________ If so, work related? ________________ work comp filed? _________________

Date of injury ___________________________________________________________________________________

Has any treatment been tried for this problem? If so please describe ______________________________________

______________________________________________________________________________________________

Please check any other foot problems you want to discuss with the doctor:
___ Hammer toes	___ Foot odor	___ Excess foot perspiration
___ Athletes Foot	___ Bunions	___ Fungal Nails
___ Other: _____________________________________________________________________________________

THE INFORMATION SUPPLIED IS CORRECT TO THE BEST OF MY KNOWLEDGE.

Signature_________________________________________________ Date __________________________________