Forms for New Patients

MEDICAL HISTORY
At Twin Cities Foot and Ankle Clinic, we believe your time is valuable. That’s why we work hard to ensure that each of our appointments begins on time.
To facilitate this promptness, we ask that you complete a few essential forms prior to your visit. The information you provide in these forms helps us to better understand your situation and the symptoms you are presenting, which will aid in creating a care plan that is customized to your needs.
Having them completed beforehand also allows you the opportunity to contemplate each question and provide an accurate and thorough response, which will save time during your office visit.

FILL OUT THE FORM BELOW OR CLICK HERE FOR A PRINTABLE MEDICAL HISTORY FORM

Medical History

Please fill out below and then SEND.

  • Date of Birth MM/DD/YYYY

  • Please indicate illness you have had.

  • Do you exercise?

  • Do you smoke?

  • Do you consume alcohol?

  • Current Medications

    List all medications, even over the counter, vitamins, herbal remedies, etc. Include the following information regarding your medications. Click the "+" sign to add more.
  • MedicationStrengthHow OftenPrescribed ByReason 

  • Allergies

    Please indicate known allergies and fill in reactions to medications or substances (e.g., latex, iodine, etc.) below.

  • Surgeries

    Please indicate any prior surgeries you have had, including wisdom teeth removal, tonsillectomy, appendectomy, etc.

  • Cramping

    Do you have cramping in your legs or feet? If yes, when?

Golden Valley

Dr. Felton | Podiatrist
Dr. Felton
Dr. Sperling | Podiatrist
Dr. Sperling

CONTACT US

Office: 763-546-1718
Fax: 763-546-1943
Email: info@tcfoot.com

GOLDEN VALLEY

5851 Duluth St., Ste 101
Golden Valley MN, 55422

GENERAL OFFICE HOURS

Monday – Thursday
8:30 a.m. – 5:00 p.m.
Friday
8:30 a.m. – 12:30 p.m.

APPOINTMENT HOURS

Monday – Thursday
9:00 a.m. – 4:30 p.m.