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Advanced Foot & Ankle Care, LLC.

Where we take it one step at a time!

2117 McComas Way ~ Ste. 102

Virginia Beach, Va. 23456

Ofc (757) 301-9996

Fax (757) 301-9958

Medical History Form

Which side?
Any previous injuries or problems to the feet, ankles, or legs?
Have you ever had a similar pain?
How many days per week do you exercise?
Do you wear store brought arch support?
Do you wear custom orthotics?
Do you suffer from any of the following?....{check all that apply}
Do you smoke?
Are you a past smoker?
Do you or your family suffer from any of the following? {Check all that apply}
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