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Dr. Rafael Lappost Foot & 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?_______________________
