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Endicott Podiatrist | Endicott Medical Information Form | NY | Mario G. Silvestri, DPM |

Mario G. Silvestri DPM, PC

Podiatric Medicine & Surgery

1003 Monroe Street

Endicott, NY 13760

607-484-3668

Office Hours
Monday:8:00am - 5:00pm
Tuesday:8:00am - 5:00pm
Wednesday:8:00am - 4:30pm
Thursday:8:00am - 5:00pm
Friday:8:00am - 4:30pm


Medical Information Form
 

Patient Name:_________________________________ D.O.B.:_____________________________

 

Patient Medical Information:

**THIS INFORMATION IS IMPORTANT FOR OUR RECORDS FOR TREATMENT AND YOU HEALTH**

 

Age:___________ Height:____________ Weight:______________ Shoe Size:___________________

 

Primary Care Physician:___________________________ Phone Number:_______________________

 

What Is The Reason For Your Visit Today?________________________________________________

 

 

PLEASE MARK ANY OF WHICH APPLY TO YOU:

 

__ Diabetes                          __ Seizure Disorders                      __ Arthritis

__ Heart Trouble                   __ Bleeding Disorders                    __ Asthma

__ Circulatory Problems         __ Hypertension(High BP)               __ Epilepsy

__ Kidney Trouble                 __ Hypotension (Low BP)                __ Hepatitis

__ Rheumatic Fever              __ Nervous Condition                      __ Stroke

__ Stomach Ulcers                __ Sickle Cell Anemia                     __ Heart Attack

__ Skin Problems                 __ Liver Disease                            __ Cholesterol Problems

__ Tuberculosis                    __ Epilepsy / Seizures                    __ Anemia

__Glaucoma                        __ Back Problems                          __ Eating Disorders

__Joint Replacements          __ Scarlet Fever                             __ Pacemaker

__Chest Pain                       __ Swelling of Feet                        __ Blood Disease

__Other:___________________________________________________________________________

 

ALLERGIES:(MARK WHAT APPLIES TO YOU)

 

__ Foods                             __ Sulphites                                __ Iodine

__ Aspirin                            __ Sulphur                                  __ Tape

__ Codeine                          __ Local Anesthesia                     __ Penicillin

__ Novocaine                       __ Dyes

__Other:___________________________________________________________________________

 

Past Surgical History:_________________________________________________________________

___________________________________________________________________________________

 

Present Medications:__________________________________________________________________

___________________________________________________________________________________

 

Family History: Diabetes, Circulatory, Hypertension, Bleeding Disorders, Arthritis, Problems with Anesthesia, Other:____________________________________________________________________

 

Social History:

Tobacco Use: Y/N (Pks/Day)________ Coffee: (Cups)_______ Alcohol:___________

 

Do You Take Aspirin Daily? Y/N Do You Faint Easily: Y/N

 
 
Endicott Podiatrist Mario G. Silvestri, DPM is a poidiatry office providing Medical Information Form, orthopedic, pain, diabetes, bunions and much more in Endicott, NY. We also do Achilles Tendonitis, Allergic Contact Dermatitis , Athlete's Foot, Brachymetatarsia, Bunions, Calluses, Diabetic Foot Care, Flatfoot (Fallen Arches), Ganglions, Haglund's Deformity, Hallux Rigidus, Hammertoes, Heel Pain/Fasciitis, Infections, Injuries, Ingrown Toenails, Metatarsalgia, Morton's Neuroma, Onychomycosis, Osteoarthritis, Pediatric Foot Care, Plantar Warts, Plantar Fasciitis, Posterior Tibial Dysfunction, Rheumatoid Arthritis, Running Injuries, Sesamoiditis, Sprains/Strains, Tarsal Tunnel Syndrome, Taylor's Bunion, Tendonitis, Toe Deformities, Xerosis and all work related in the 13760 area and surrounding areas in Endicott
 

Mario G. Silvestri, Dpm