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LoneStar Foot & Ankle Group
+1 (817)-573-3338
1200 Crawford Ave. Suite C Granbury, TX 76048
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About Us
New Patients
Insurance Information
FAQ’s
Services
Fractures
Arthritis
Bunion
Diabetic Footcare
Fractures
General Podiatry
Hammertoe
Joint Replacement
Joint Fusion
Orthotics
Pediatric Surgery
Reconstructive surgery
Sports Medicine
Trauma
Wound Care
Blog
Contact Us
Get Appointment
Menu
Home
About Us
New Patients
Insurance Information
FAQ’s
Services
Fractures
Arthritis
Bunion
Diabetic Footcare
Fractures
General Podiatry
Hammertoe
Joint Replacement
Joint Fusion
Orthotics
Pediatric Surgery
Reconstructive surgery
Sports Medicine
Trauma
Wound Care
Blog
Contact Us
Get Appointment
Menu
Home
About Us
New Patients
Insurance Information
FAQ’s
Services
Fractures
Arthritis
Bunion
Diabetic Footcare
Fractures
General Podiatry
Hammertoe
Joint Replacement
Joint Fusion
Orthotics
Pediatric Surgery
Reconstructive surgery
Sports Medicine
Trauma
Wound Care
Blog
Contact Us
Get Appointment
Menu
Home
About Us
New Patients
Insurance Information
FAQ’s
Services
Fractures
Arthritis
Bunion
Diabetic Footcare
Fractures
General Podiatry
Hammertoe
Joint Replacement
Joint Fusion
Orthotics
Pediatric Surgery
Reconstructive surgery
Sports Medicine
Trauma
Wound Care
Blog
Contact Us
Get Appointment
PAST MEDICAL HISTORY
First Name
Last Name
HEENT
Allergies
Blindness
Cataracts
Sinus Problems
Glaucoma
Hearing loss
Macular degeneration
Blindness
Other
RESPIRATORY
Ashtma
Bronchitis
COPD
Emphysema
Pneumonia
Tuberculosis
Other
NEUROLOGICAL
Epilepsy
Head injury/concussion
Headaches
Migraines
Seizures
Stroke
Other
CARDIOVASCULAR
Atrial fibrillation
Circulatory Problems
Congestive heart failure
Heart disease
Heart attack, when?
Hypertension
GASTROINTESTINAL
Celiac Disease
Crohns Disease
Eating disorder
Hepatitis
Irritable bowel syndrome
Pancreatitis
HEMATOLOGY/CANCER
Anemia
Blood Clots
Breast Cancer
Colon Cancer
Prostate Cancer
Cancer Other
URINARY/CANCER
BPH
Kidney Disease
Urinary Incontinence
Other
ENDOCRINE
Diabetes I; age of onset
Diabetes II; age of onset
Gestational Diabetes
Hyperthyroidism
Hypothyroidism
Other
RHEUMATOLOGIC
Fibromyalgia
Gout
Lupus
Osteoarthritis
Other
PSYCHIATRIC
Alcohol Problems
Anxiety
Depression
Drug Problems/Addictions
Other
MUSCULOSKELETAL
Arthritis
Osteoporosis/Osteopenia
Scoliosis
Other
STD’s
AIDS/HIV
Genital herpes
Chlamydia/Gonorrhea
Genital warts (HPV)
Other
PAST SURGICAL HISTORY
SURGERY
REASON
YEAR
HOSPITAL
REVIEW OF SYSTEMS
CONSTITUTIONAL
Fever
Night Sweats
Weight Loss
Dizziness
EYES
Dry Eyes
Visual Disturbances
Irritation
GENITOURINARY
Urinary loss of control
Difficulty Urinating
Increased frequency
Blood in urine
Incomplete Emptying
CARDIOVASCULAR
Chest pain on exertion
Heavy chest
Tarry stools/ blood
Leg pain on exertion
Irregular heart beats
GASTROINTESTINAL
Abdominal pain
Vomiting
Change in Appetite
Sore throat
Diarrhea
Trouble Swallowing
RESPIRATORY
Cough
Wheezing
Shortness of Breath
Coughing up Blood
Sleep Apnea
Snoring
Fainting
NEUROLOGICAL
Loss of consciousness
Depression
Weakness
Numbness
Seizures
Dizziness
Restless legs
Memory loss
Migraines
INTEGUMENTARY
Changes in moles
Jaundice
Eczema
Rash
Dry skin
Growth/lesions
HEMATOLOGIC
Swollen Glands
Easy Bruising/Bleeding
ENDOCRINE
Fatigue
Increased Thirst
Increased Hunger
ALLERGIES
ALLERGY
REACTION
MEDICATIONS
DRUG NAME
STRENGTH
FREQUENCY TAKEN
FAMILY HEALTH HISTORY
RELATION
ALIVE
AGE
SIGNIFICANT HEALTH PROBLEMS
Grandmother Maternal
Grandfather Maternal
Grandmother Paternal
Grandfather Paternal
Father
Mother
Brother/Sister
Other
SOCIAL HISTORY
Education
< 12th grade
High school
Associates
Bachelors
Masters
Doctorate
Caffeine
Alcohol
Tobacco
Drugs
Father
Mother
Brother/Sister
Other
Main reason for today’s visit? (please be specific)
Which extremity is bothering you today?
Right
Left
Both
History of present illness/injury
Check all that apply:
Dull
Throbbing
Sharp
Electrical
Shooting
Intermittent
Constant
Burning
Aching
Pins/needles
Worse in AM
Worse in PM
Rate your pain on below scale:
0-1
2-3
4-5
6-7
8-9
10
RWhat makes the pain worse?
What makes the pain better?
What have you done for the problem?
Have you had the problem before? Same area?