Harry Cotler

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Harry Cotler, D.P.M.

Affiliated Foot & Ankle Care
35670 Kenai Spur Highway, Suite 102
Soldotna, AK 99669
(907) 260-3668 (Foot)
footdoc@alaska.net

Medical History - New Patient Questionnaire

Page 1 of 2

As a new patient, you have a lot of background to share with your new Podiatrist. Use this template when you are visiting Dr. Cotler for the first time. Fill this out to bring with you to the appointment to simplify the registration process. Keep a copy for your records so that it is available when you need to visit other doctors.

IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page in 'LANDSCAPE FORM' now so you don't lose your information.

First Name: MI: Last Name:

Soc. Sec. No.:     I prefer to be addressed as:

Occupation:       Sex: MF    Age:

Birthday:     Shoe Size:    Weight:     Height:

Phone Numbers for Contacting You:
Day: Evening: Cell:

In Case of Emergency, Please Call:
Name:     Day:     Evening:

Please Provide Your Preferred Pharmacy:
                                       Name:

                                       Street/City:

                                       Phone #:

Is there anyone in your family with heart disease, high blood pressure, diabetes, kidney, cancer or other medical problems? Yes No

Please list any conditions and select how the person is related to you.

Condition:		Relationship:
Condition:		Relationship:
Condition:		Relationship:
Condition:		Relationship:
Condition:		Relationship:

List your current physicians.

    Specialty:

    Specialty:

    Specialty:

Enter the date of your last physical exam and list the physician who saw you.

Month:		Date:		Year:
Physician:

(Women only) Enter the date of your last OB/GYN exam and list the physician who saw you.

Month:		Date:		Year:
Physician:

List any medical conditions you have and for how long you've had the condition (first month/year diagnosed)

Condition:	Month:	Year:
Condition:	Month:	Year:
Condition:	Month:	Year:
Condition:	Month:	Year:
Condition:	Month:	Year:

Have you ever gone to an emergency room for treatment in the last year? Yes No
How many times in the past year?
List the reason and when you made each ER visit.

Reason:	Month:	Year:
Reason:	Month:	Year:
Reason:	Month:	Year:

Have you ever stayed in the hospital overnight during the past year? Yes No
How many times in the past year?
List the reason and when you stayed overnight.

Reason:	Month:	Year:
Reason:	Month:	Year:
Reason:	Month:	Year:

Have you had surgery? Yes No
List the type of surgery or reason for surgery including dates.

Reason:	Month:	Year:
Reason:	Month:	Year:
Reason:	Month:	Year:

List any allergies you have to food or medications. Tip: Only 5 lines available, so summarize.

Have you ever had an anaphylactic reaction (turning red, overall swelling, difficulty breathing)? Yes No

Do you smoke? Yes No
Select which products you use, how much, and number of years used.

Tobacco product:
How much:
Years:

Do you drink alcohol? Yes No
How many of each do you drink a day?

Beer:

Wine:

Liquor:

Do you take any recreational drugs? Yes No

Are you taking any prescription drugs currently? Yes No
List drugs, dosage, and how often you take them.

Drug Name:	Dosage:	How often:
Drug Name:	Dosage:	How often:
Drug Name:	Dosage:	How often:

(Your Additional Question Goes Here.) Tip: Only 5 lines available, so summarize.

Next Page

IMPORTANT TIP: The information you entered is not saved to protect your privacy. Please print this page now so you don't lose your information.

Home / About the Doctor / Services / Order Shoes Online / Diagnostic Ultrasound
Vascular Examination / 3D Foot Imaging /Directions / New Patient Forms / Payment Information
HIPPA Patient Privacy Mission Statement / Diabetic Update/ Family Page