Dr. Rafael LappostFoot & Ankle Joint Specialist

Email / Correo Electronico

Past Medical History / Historia Clinica

Date of Birth/Fecha de Nacimiento

Social Security #/ Numero de Seguro Social

PCP / Medico Primario_____________________________________________________________________________________

Do You Smoke/ Fuma?__________ Number of Cigarettes or PPD/Cuantos Cigarros al dia?______________________________

Do you drink Alcohol/Bebe Alcohol?__________ How much/Cuantas copas?__________________________________________

Do you use Drugs/Usa Drogas?_____________________________________________________________________________

Have you seen a Podiatrist/Se a visto con un Podiatra antes?_________ Who/Quien?__________________________________

Have you seen a Vascular specialist/A visto un especialista Vascular antes?________ Who/Quien?_______________________