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APPENDICES
PODIATRY RECORDS (fac-simile)
SOCIAL PERSONAL DATA
name and surname: sex F M date of birth: place of birth:
address:
weight (kg): height (cm):
phone number: mobile number: GP: medical specialist:
THERAPEUTIC MEDICAL HISTORY
Conservative treatment
RECENT MEDICAL HISTORY
prescribed
implemented
Roman
OBJECTIVE TESTS:
Foot type:
type of footwear: degree of wear: orthotic device in use:
Egyptian
Greek
FACTORS
education:
structure of family unit:
FAMILY MEDICAL HISTORY
size:
disorders of genetic and/or hereditary transmission:
eg chromosomal abnormalities, cardiovascular, skin, blood,
endocrine,
gastrointestinal, genitourinary, lymphatic, metabolic,
skin condition:
temperature:
wrists:
changes in skin features – hairs: changes in skin features – nails: interdigital maceration: hyperkeratosis:
tylosis:
musculoskeletal, neuropathic, eye, oncological, respiratory, hearing
PHYSIOLOGICAL HISTORY
childbirth:
first menstruation: age ____ menstrual cycle
MORPHOLOGICAL ASSESSMENT
anatomical completeness changes in soft tissue deformities of forefoot changes in morphology
FUNCTIONAL ASSESSMENT TEST
profession (current or previous):
regular
early onset urination:
coffee
physical activity
denture
whooping cough
other
skin allergies:
other diseases:
autoimmune:
cardiovascular
lymphatic:
blood, endocrine, hepatic, infectious, metabolic, oncological, musculoskeletal, respiratory, serological, renal, etc.
Menopause: onset bowel function: Lifestyle:
diet
alcohol
sedentary lifestyle
devices in use corrective glasses
EARLY MEDICAL HISTORY
common childhood illnesses: other childhood illnesses:
food intolerances: previous surgery:
irregular induced
smoking other
other
mumps
postural alignment
abnormal twisting of limbs
structural relationship between heel and forefoot knee
heel
MANUAL ASSESSMENT
muscle strength joint mobility: surface sensitivity:
– thermal
pain sensitivity
– surface tactile sensitivity achiness
deep sensitivity:
– kinesthetic
– vibration perception
– pressure sensitivity tendon reflexes:
– patellar reflex – achilles reflex
PHARMACOLOGICAL HISTORY
antiplatelet therapy antihypertensive therapy hypouricemia therapy phlebolymphotropic therapy
anticoagulant therapy hypoglycemic therapy hypolipidemic therapy prescribed implemented
hypertension
hypotension
THE EUROPEAN JOURNAL OF LYMPHOLOGY - Vol. XXIX - Nr. 75 - 2017
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