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CAROLINA MUSCULOSKELETAL INSTITUTE, PA
PODIATRY DIVISION – DISEASES AND SURGERY OF THE FOOT MACKIE J.WALKER, JR.,DPM ANGELA H. MOLNAR, DPM
NAME __________________________________________________________________________ BIRTH DATE _____/_____/_____ AGE _______ YRS ADDRESS ________________________________________________________________________ CITY_____________________ ZIP _________________ SSN____________/____________/____________ HOME PHONE __________________________________CELL PHONE _______________________ MARITAL STATUS__________________________ REFERRED BY ____________________________________________________________________ PRIMARY PHYSICIAL (FAMILY DOCTOR)________________________________________ DATE OF LAST VISIT___________________ RESPONSIBLE PARTY (IF PATIENT IS A MINOR) ____________________________________SSN ___________________________________ EMPLOYER __________________________________________________________________LENGTH OF EMPLOYMENT____________________ EMPLOYER ADDRESS ______________________________________________________TELEPHONE ______________________________________ SPOUSE’S NAME _______________________________________________________________SPOUSE’S BIRTH DATE _______/_______/_______ SPOUSE’S SSN ____________/____________/____________ SPOUSE’S EMPLOYER ____________________________________________________ IN CASE OF EMERGENCY, NOTIFY ___________________________________________PHONE _______________________________________ IF YOUR PROBLEM IS THE RESULT OF AN INJURY AT WORK, DO YOU HAVE WORKER’S COMPENSATION COVERAGE? □ YES □ NO THANK YOU FOR COMPLETING THE ABOVE FORM.
PLEASE READ THE STATEMENTS BELOW, SIGN YOUR NAME, AND DATE.
WE APPRECIATE YOU CHOOSING US TO PROVIDE YOUR MEDICAL CARE!
CERTIFICATION: I DO HEREBY STATE THE INFORMATION PROVIDED ABOVE IS CORRECT TO THE BEST OF MY KNOWLEDGE. PAYMENT GUARANTEE: I HEREBY AGREE TO PAY THE ESTABLISHED RATES OF THIS OFFICE FOR ALL SERVICES RENDERED TO ME OR MY DEPENDENTS WHILE I AM/THEY ARE UNDER THE CARE OF CAROLINA MUSCULOSKELETAL INSTITUTE, PA. ASSIGNMENT OF BENEFITS AND AUTHORIZATION TO RELEASE INFORMATION: I DO HEREBY AUTHORIZE CAROLINA MUSCULOSKELETAL INSTITUTE, PA TO PERMIT ANY INSURER PROVIDING ME OR MY DEPENDENTS UNDER THEIR CARE TO INSPECT THE MEDICAL RECORD IN CONNECTION WITH ANY CHARGES ARISING FROM MY TREATMENT IN THIS OFFICE. I FURTHER AUTHORIZE ANY SUCH INSURER TO PAY DIRECTLY TO CAROLINA MUSCULOSKELETAL INSTITUTE, PA ANY PAYMENTS FOR CHARGES ARISING FROM SERVICES TO ME. SIGNATURE:________________________________________________________DATE:_______________________________________WITNESS:_____________________________________ MEDICAL HISTORY INFORMATION SHEET DATE ________/________/________
MACKIE J. WALKER, JR., DPM ANGELA H. MOLNAR, DPM
IMPORTANT! PLEASE READ THE QUESTIONS BELOW CAREFULLY. PLEASE ANSWER ALL QUESTIONS SO THAT THE DOCTOR MAY
EVALUATE YOUR PROBLEM IN THE MOST THOROUGH MANNER AND PROVIDE YOU WITH THE BEST POSSIBLE CARE. NAME __________________________________________________________________________________ BIRTH DATE________/________/________ AGE__________YRS SEX __________ RACE___________ HEIGHT________FT________IN WEIGHT __________LBS SHOE SIZE ___________ LENGTH_________WIDTH WOMEN, ARE YOU PREGNANT? □ YES ____________ MONTHS □NO □MAYBE NATURE OF COMPLAINT/PROBLEM
RIGHT FOOT ______________________________________________________________ ONSET__________________________ DURATION__________________ LEFT FOOT ________________________________________________________________ ONSET__________________________ DURATION__________________ ASSOCIATED PROBLEMS ______________________________________________________________________________________________________________________________ ____________________________________________________________________________________________________________________________________________________________ PAST PODIATRIC MEDICAL HISTORY
FORMER PODIATRIST _________________________________________________________________DATE OF LAST VISIT _____________________________ ALLERGIES (PLEASE CHECK IF YOU ARE ALLERGIC TO) □ NOVACAINE □ PENICILLIN □ IODINE □ ADHESIVE TAPE □SULFA DRUGS
□ OTHER MEDICATIONS (PLEASE LIST) __________________________________________________________________________________________________ MEDICATIONS (NAME AND DOSAGE) _______________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________ HAVE YOU OR YOUR FAMILY EVER BEEN TREATED FOR ANY OF THE FOLLOWING CONDITIONS/PROBLEMS?
HEART PROBLEMS □YOU □FAMILY
KIDNEY PROBLEMS □YOU □FAMILY
KELOID SCARS □YOU □FAMILY
LIVER PROBLEMS □YOU □FAMILY
STOMACH PROBLEMS □YOU □FAMILY
HIGH BLOOD PRESSURE □YOU □FAMILY
ARTHRITIS □YOU □FAMILY
BRUISE EASILY □YOU □FAMILY
SLOW HEALING TIME □YOU □FAMILY
CANCER □YOU □FAMILY
ASTHMA □YOU □FAMILY
LUNG PROBLEMS □YOU □FAMILY
EPILEPSY □YOU □FAMILY
GOUT □YOU □FAMILY
RHEUMATIC FEVER □YOU □FAMILY
AIDS/HEPETITIS/OTHER RELATED DISEASES □YOU □FAMILY OTHER _____________________________________________________________
ARE YOU DIABETIC? □NO □ YES
IF YES, DATE OF LAST BLOOD SUGAR ________________________________RESULTS_____________ OPERATIONS/ILLNESSES/INJURIES (DATES) ______________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________________________________________ HAVE YOU EVER RECEIVED GENERAL ANESTHESIA? □NO □ YES ANY PROBLEMS? ______________________________________________ PACKS/DAY ____________________ DO YOU DRINK? □NO □ YES AMOUNT/DAY ____________ DO YOU FREQUENTLY HAVE LEG CRAMPS? □NO □ YES IF SO, WHEN? _____________________________________________________________ GENERAL AND INFORMED CONSENT FOR TREATMENT: I HEREBY REQUEST AND AUTHORIZE CAROLINA MUSCULOSKELETAL
INSTITUTE, PA OR ITS DESIGNEE TO ADMINISTER TREATMENT AND TO PERFORM SUCH GENERAL PROCEDURES AS MAY BE
NECESSARY IN THE DIAGNOSIS AND TREATMENT OF MY FOOT CONDITION. I FURTHER CERTIFY THAT THE INFORMATION
PROVIDED IN THE MEDICAL HISTORY ABOVE IS TRUE AND ACCURATE.
SIGNATURE: ______________________________________________________________ DATE: _____________________________ WITNESS: _____________________________ PODIATRIC EXAMINATION TO BE COMPLETED BY THE DOCTOR
CAROLINA MUSCULOSKELETAL
INSTITUTE, PA
MACKIE J. WALKER, JR., D.P.M. ANGELA H. MOLNAR, D.P.M. PATIENT’S NAME ______________________________________________________________ DATE OF BIRTH _____/_____/_____ VITAL SIGNS: BY __________ PULSE __________/MIN; TEMP__________°F; RESP ________/MIN; B.P. ______/_____(R) (L)
INTEGUMENT

MOISTURE
HAIR DIST.
___________CONDITION OF TOE NAILS_____________
□ Hypertrophic nail plate(s):____________________________
□ Discoloration of nail plate(s):__________________________
□ Subungual debris of:___________________________________
□ Onycholysis: _______________________________________ □ Onychocryptosis: ____________________________________ OTHER FINDINGS:______________________________________ □ Paronychia: _________________________________________ □ Other __________________________________________ VASCULAR
DORSALIS
POSTERIOR
POPLITEAL A
CFT (sec)
VARICOSITIES
OTHER FINDINGS: ___________________________________________________________________________________________ NEUROLOGICAL
MOTOR REFLEXES
SENSORUM
PATHOLOGICAL –(+)
PATELLAR
ACHILLES
SHARP/DULL
LIGHT TOUCH
MONOFILAMENT
VIBRATORY
BABINSKI
RHOMBERG
FI
F RIGHT
OTHER FINDINGS: __________________________________________________________________________ MUSCULO-SKELETAL
MUSCLE STRENGTH
RANGE OF MOTION OF JOINTS
INVERSION
EVERSION
DORISIFLEXION
PLANTARFLEXION
SUBTALAR
MIDTARSAL
FIRST MPJ
FOOT TYPE-STANDING
MILD PLANUS
MOD PLANUS
SEV PLANUS
MILD CAVUS
MOD CAVUS
SEV CAVUS
GAIT ANALYSIS: _____________________________________________________________________________________________________ LIMB LENGTH: ________________________________________________ POSTURE: ____________________________________________ DEFORMITIES

OTHER FINDINGS:___________________________________________________________________________________________ ADDITIONAL NOTES/FINDINGS: ________________________________________________________________________________________ ___________________________________________________________________________________________________________________ ___________________________________________________________________________________________________________________ (Continued in Progress Notes) __________________________________________________________________ DPM Date ______/______/______ PATIENT’S NAME ____________________________________________ DOB _____/_____/_____ TEL. _________________ ALLERGIES: ________________________________________________ CHRONIC DISEASES: __________________________ INITIAL PROGRESS NOTES
SEE HISTORY AND PHYSICAL
X-RAY STUDIES ORDERED (if ind.) TO: □ AP □ LAT □ OBL □ OTHER- FINDINGS: OTHER STUDIES ORDERED (if any): IMPRESSIONS: RECOMMENDATIONS/ADVISE: □ NATURE OF ABOVE CONDITIONS, ETIOLOGY, AND TREATMENT MODALITIES AVAILABLE FOR SAME: WRITTEN / ORAL INSTRUCTIONS / INFORMATION GIVEN RE: □ RE SHOE GEAR: □ SEE PT PLAN □ WHIRLPOOL _______ MINUTES □ INJECTION (Dose/Site): □ DISPENSED □ Rx □ PARING OF LESIONS WITH SCAPEL □ MANUAL / MECHANICAL DEBRIDEMENT OF NAILS _____________ FT. □ OTHER PTR ______________ □ Days □Weeks □ Months ______________________________________________________________ DPM Date ______/______/______

Source: http://www.cmi.md/docs/Podiatry_newpatientforms.pdf