Patient Update Questionnaire

Please complete all required fields!

First Name (*)

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Last Name (*)

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Phone (*)

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Have you been prescribed any new medications since your last visit?

Yes No Invalid Input

What are these medications?

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Are you allergic to any medications?

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If you are Diabetic:

When was your last visit to your primary physician?

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What was your fasting blood sugar level this morning?

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What was your latest A1C level?

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Have you had an injury to your foot since your last visit?

Yes No Invalid Input

If yes, please explain:

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Have you had any surgeries since your last visit?

Yes No Invalid Input

If yes, please explain

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Are you experiencing any other foot ailments besides what your appointment is scheduled for today?

Yes No Invalid Input

If yes, please explain

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Have you been diagnosed with a new condition by another doctor?

Yes No Invalid Input

If yes, please explain (include date diagnosed & treatment)

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Do you have a living will or an advanced directive for end-of-life medical care?

Yes No Invalid Input

If no, name a person who will make decisions for you?

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Please be aware that we have allotted a specific amount of time for your appointment today. If there are other foot ailments or concerns that you would like Dr. Vail to address at this visit we will make every effort to accommodate you, but we may have to re-appoint you to be able to afford you and all our patients quality time with their appointment.

By typing your name below, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual signature on this form.

Electronic Signature (*)

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