New Patient Form

Dr. Affan Akhtar/Dr. Humaira Syed
Reds Ankle & Foot Associates
1211 Hamburg Turnpike, Suite 100
Wayne, NJ 07470
Tel: (973) 692-1111

 Yes No

 YES NO


Insurance Information



PLEASE LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING(INCLUDE PRESCRIPTIONS,OVER-TIME-COUNTER MEDS AND HERBAL SUPPLEMENTS):

Name
Dose
How often do you take?













 Single Married Partnered Seperated Divorced Widowed

 Never No Longer Use History of Alcohol Abuse

 Rare Occasional Moderate Daily

 Never Quit-How long ago Smoke

 Never Quit How Long ago

 current use type Rere Occasional Moderate Daily

 10% 25% 50% 75% 100%

 Childerns Age Pets What kind?

 Elderly or Disable Family Members Others

 Never Rare Occasional Weekly Several Times A Week Daily

Family History

 Diabetes Cancer Heart Disease High Blood Pressure Stroke Coronary Artery Disease Thyroid Disease Rheumatoid Arthritis

 other

Your Medical History

 None Known Medications

 Anesthesia foods

 Tape Latex Shellfish Iodine Others

  • Acid Reflux
  •  Yes No
  • Anemia
  •  Yes No
  • Arthrise
  •  Yes No
  • Asthma
  •  Yes No
  • Back Trouble
  •  Yes No
  • Bladder Infections
  •  Yes No
  • blood clots
  •  Yes No
  • blood transfusion
  •  Yes No
  • bronchitis/emphysema
  •  Yes No
  • cancer
  •  Yes No
  • diabetes
  •  Yes No
  • fibromyalgia
  •  Yes No
  • gout
  •  Yes No
  • heart attack
  •  Yes No
  • heart disese/failure
  •  Yes No
  • hepatitis
  •  Yes No
  • hiv/aids
  •  Yes No
  • high blood pressure
  •  Yes No
  • kidney disease
  •  Yes No
  • liver disease
  •  Yes No
  • low blood pressure
  •  Yes No
  • migraine headaches
  •  Yes No

  • mitral valve prolapse
  •  Yes No
  • nueropathy
  •  Yes No
  • open sores
  •  Yes No
  • pnuemonia
  •  Yes No
  • polio
  •  Yes No
  • rheumatic fever
  •  Yes No
  • sickle cell disease
  •  Yes No
  • skin disorder
  •  Yes No
  • sleep apnea
  •  Yes No
  • stomatch ulcers
  •  Yes No
  • stroke
  •  Yes No
  • thyroid disease
  •  Yes No
  • tuberculosis
  •  Yes No

Current Problem

 Top of Foot Bottom of Foot Inside of Foot Outside of Foot

 Bottom of Foot Top of Foot Outside of Foot Inside of Foot

 Days Week Month Year

 Begin all of a Sudden Gradually Develope over time

 No pain Sharp Dull Aching Burning Radiatiog Itching Stabbing Other

 0 1 2 3 4 5 6 7 8 9 10

 Stayed the same Become worst Improved

 Walking Standing Daily Activities Resting Dress shoes High Heels Flat shoes Any closed Toe Shoes Running

 Yes No



TO THE BEST OF MY KNOWLEDGE, I HAVE ANSWERED THE QUESTIONS ON THIS FORM ACCURATELY.I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH.I UNDERSTAND THAT IT IS MY RESPONSIBILITY TO INFORM THE DOCTOR AND OFFICE STAFF OF ANY CHANGES IN MY MEDICAL STATUS.





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