Park Center Foot & Ankle Clinic RANDY E. LOWE, DPM - PatientPop

Park Center Foot & Ankle Clinic RANDY E. LOWE, DPM Have you been seen in our office before? No Yes — Approx. Date: Visit Date: Last Name First Name PATIENT INFORMATION Middle DOB Age / Street Address City Social Security No. Home Phone ( Preferred Cell Phone ( Can we leave a message? Yes No Employer Preferred ) Zip Would you like a text reminder approx. 2 business days prior visits? Yes No Occupation Address RACE Decline to Report White Asian Native Hawaiian Other Pacific Islander Black/African American More than one race City, State, Zip ETHNICITY Decline to Report Hispanic/Latino Not Hispanic/Latino IN CASE OF EMERGENCY Local friend/relative (not living at same address) Relation Home Phone Guarantor Name Email Address Sex M F Marital Status Single Married Would you like patient portal access? Divorced No Yes (email required) Separated Work Phone Preferred Widow Other ( ) State Email Address ) / PREFFERED English LANGUAGE Other: Work Phone PARENT/LEGAL GUARDIAN INFORMATION (Required only if patient is under 18 years old) SS# Sex DOB Age M F / / Best Contact # Home Work Cell Can we leave a message? Yes No Street Address City, State, Zip CHOSE CLINIC Location Insurance Plan Yellow Pages BECAUSE Other: Relation REFERRED Insurance Physician Other BY INSURANCE INFORMATION Primary Ins. Co Employer Policy # Policyholder Group # DOB Secondary Ins. Co Self Spouse Dependent Employer Policy # Policyholder Relation Group # DOB Relation Self Spouse Dependent ALL PATIENTS PLEASE READ & SIGN I authorize payment of medical benefits from Medicare, Medigap, private and/or group insurance be made on my behalf to Park Center Foot & Ankle Clinic for any services or supplies furnished to me. I authorize any holder of medical information about me to release to the Health Care Financing Administration or my insurance company any information needed to determine benefits for related services. I also take responsibility for payment of charges, regardless of payment or denial of payment from my insurance company. Patient or Patient Representative Relation (if not self) Date

230 W. Mallard Dr. #C Boise, ID 83706 Park Center Foot & Ankle Clinic Tel 208.387.0900 Doctor of Podiatric Medicine & Certified Surgeon Fax 208.345.5883 Randy E. Lowe, DPM Patient Name Current Concerns Visit Date Describe Issue Toes Circle Foot Area(s) Right Great 2nd 3rd Affected Left Great 2nd 3rd aching stabbing Quality burning throbbing gnawing sharp Current cane Aids Include rolling walker How long has it bothered you? Days Wks cannot identify Timing acute chronic Other 4th 5th Nail Heel Arch Ball Side Top Joints Ankle Entire Foot 4th 5th Nail Heel Arch Ball Side Top Joints Ankle Entire Foot dull occasional worsening pain level /10 no pain mild superficial frequent improving Severity moderate severe deep constant not changing folding walker crutches roll-about wheel chair Months Yrs abrupt gradual morning continuous since onset? daytime nighttime recurrent surgical boot occasional accident related? no yes, details: rare occasional intermittent episodes lasting: other: Improves with nothing helps sitting standing lying down position change heat ice rest elevation exercise stretching limited weight bearing PT/OT OTC medication narcotics NSAIDs Worse with brace crutches cane wheelchair walker flat shoes heels removal of shoes Other: ASSOCIATED weakness SYMPTOMS numbness other: cannot identify sitting standing lying down walking lifting range of motion weight bearing morning daytime nighttime cold weather damp weather barefoot flat shoes wearing heels Other: tingling swelling redness warmth instability radiation down leg PREVIOUS FOOT SURGERIES (note procedure, which foot & approx. year) None drainage other: PRIOR IMAGING none x-ray MRI labs ultrasound Prior Injections comments: None Relief: did not help helped a little temporarily significantly orthotics comments: Other night splint Treatments physical therapy None other Relief: did not help helped a little temporarily significantly Please complete the other side

REVIEW OF SYSTEMS Please indicate if you have had any of the following issues in the past 30 days. Constitutional excess weight gain excess weight loss loss of appetite fever diminished activity fatigue Eyes eye issues ENMT ear issues sinus pressure congestion sore throat hoarseness foul smelling breath mouth lesions Cardiovascular chest pain rapid heart rate Respiratory cough bark-like cough wheezing chest tightness pain with respiration rapid respirations difficulty breathing Gastrointestinal difficulty swallowing abdominal pain nausea vomiting diarrhea constipation Musculoskeletal soft tissue swelling joint swelling myalgia limited motion previous injuries trauma None of these apply Neurological Symptoms numbness weakness tingling burning shooting pain headache dizziness loss of consciousness Psychiatric depression anxiety insomnia stress loss of interest Skin pain itchiness dry skin flaking redness rash hives skin lesions skin growths skin lumps bruising insect bites Endocrine increased thirst increased drinking temperature intolerance Allergic/Immunologic sneezing runny nose

Patient Name 230 W. Mallard Dr. #C Boise, ID 83706 Tel 208.387.0900 Fax 208.345.5883 Park Center Foot & Ankle Clinic Doctor of Podiatric Medicine & Certified Surgeon Randy E. Lowe, DPM Visit Date Patient History Primary Care Physician Preferred Pharmacy Weight Height MEDICATION ALLERGIES No Known Allergies DIABETES No Yes Address/Cross Roads Body mass index (BMI) is a general measure of body fat based on height & weight. We are required to notify you that if you are outside the normal parameters you are at a higher risk of many diseases that affect your overall health including: heart disease, high blood pressure, diabetes, gallstones, breathing problems, and certain cancers. We have your BMI on file if you do not currently know yours. If you are outside the normal parameters, we recommend you seek guidance from your primary care physician regarding your target weight and develop a plan to enjoy the healthy benefits of diet & exercise. The normal ranges are: ages 18 - 64 is 18.5 - 25 and for ages 65 yrs & older it is 23 - 30. VACCINES Last Visit Latex NSAIDS Adhesives Anesthesia Aspirin Novocain Penicillins Sulfa Drugs Other: Codeine Iodine Influenza No Yes, in the past 12 months approx. date Pneumonia No Yes, in the past 5 years approx. date Diagnosed (approximate year) Type: I II Pre-Diabetic Treatment ( all that apply) Insulin Oral Medication Lifestyle Controlled (Acceptable A1C ) Yes No Unknown Related Issues Neuropathy/Nerve Pain Ulcer History Slow Healing Managed by Primary Care Provider Other: Brother Sister Indicate family history of the following NONE Father Mother OTHER CONTRIBUTING Chronic Pain Syndrome Fibromyalgia RA Other: PROBLEMS Arthritis Tobacco Never Quit (approx. year) Smoke approx # packs per wk Cancer Diabetes EXERCISE Foot Deformity Heart Disease Hypertension Alcohol Never Occasionally (less than 1 drink/week) Moderate (less than 3 drinks/day & 7/wk) Heavy Limited/None Occasional (can walk 3 blocks) Moderate (30 min x 2-3/wk) Heavy (30 min x 4 /wk) ANY PREVIOUS SURGERIES Year (approx) No Past Surgeries List Attached Procedure Poor Circulation Yes, I am currently pregnant weeks PAST HEALTH HISTORY Any history of the following: AIDS/HIV Edema Hepatitis Anemia Fibromyalgia Hernia Arthritis Foot Problems Hypertension Artificial Joints Frost Bite Insomnia Bleeding Disorder GERD/Heartburn Kidney Disease Cancer Gout Leg/Foot Ulcers Diabetes Headaches Liver Disease Dialysis Heart Disease Lung Disease Comments: None MRSA Nerve Disorder Organ Transplant Osteoporosis Pacemaker Peripheral Vascular Disease Psych Disorder Rheumatoid Arthritis Sciatica Sleep Apnea Stroke Substance Abuse Thyroid Problems Tuberculosis Varicose Veins

230 W. Mallard Dr. #C Boise, ID 83706 Tel 208.387.0900 Fax 208.345.5883 Medications Include OTC, Prescriptions, Supplements & Vitamins Patient Name Visit Date Pt. Init. Medication Aspirin Visit Date Pt. Init. Doctor of Podiatric Medicine & Certified Surgeon Randy E. Lowe Date Park Center Foot & Ankle Clinic Dose 81 mg Visit Date I do not take any medications regularly List attached Form Route Schedule tab, spray by mouth, inhale 1 tab/day, 1 tab twice daily, every 8 hrs Pt. Init. Visit Date Pt. Init. Visit Date Pt. Init. Visit Date Pt. Init. DC Visit Date Pt. Init.

Boise, ID 83706 Tel 208.387.0900 Fax 208.345.5883 Park Center Foot & Ankle Clinic Doctor of Podiatric Medicine & Certified Surgeon Randy E. Lowe, DPM Describe Issue Circle Area(s) Affected Left Foot Toes Other Right Great 2nd 3rd 4th 5th Nail Heel Arch all Side Top Joints Ankle Entire Foot Great 2nd 3rd 4th 5th Nail Heel Arch all Side Top .