New Patient Form

New Patient Information Form

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Please fill out this form completely.

At the end of the form there is a "SUBMIT" button that will send it directly to Optima Foot and Ankle. Thank you.
Patient Information
How did you first hear about us?
Referred by?
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*

MaleFemaleOther
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Primary Phone #*

Area CodePhone Number
Secondary Phone #

Area CodePhone Number
Social Security Number
Occupation*
Martial Status*

MarriedSeparatedDivorcedSingleWidowedPartnerOther
Preferred Language*

EnglishSpanishOther
Race*

American Indian or Alaska NativeAsianNative HawaiianBlack or African AmericanWhiteHispanicOther Pacific IslanderOther RaceUnreported/Refused to Report
Ethnicity*

Hispanic or LatinoNOT Hispanic or LatinoUnreported/Refused to Report
Medical Insurance
Do you have Medical Insurance? If no, please continue to the next section "Health History".*

YesNo
PRIMARY Medical Insurance Name*
PRIMARY Medical Insurance - Subscriber ID #*
PRIMARY Medical Insurance - Group #
PRIMARY Medical Insurance - Subscriber Name*

First NameLast Name
PRIMARY Medical Insurance - Subscriber Date of Birth

MonthDayYear
Date
PRIMARY Medical Insurance - Relation to Patient

SelfSpouseParentOther
Do you have a SECONDARY Medical Insurance Plan?

YesNo
SECONDARY Medical Insurance Name (If you answered YES)
SECONDARY Medical Insurance - Subscriber ID # (If you answered YES)
SECONDARY Medical Insurance - Group # (If you answered YES)
SECONDARY Medical Insurance - Subscriber Name (If you answered YES)

First NameLast Name
SECONDARY Medical Insurance - Subscriber Date of Birth (If you answered YES)

MonthDayYear
Date
SECONDARY Medical Insurance - Relation to Patient (If you answered YES)

SelfSpouseParentOther
Health History
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Height (in feet and inches)*
Weight (in pounds)*
Shoe Size*
What Pharmacy are you likely to use? (Name and Location)
Who is your Primary Care Physician?*
Date last seen?*

MonthDayYear
Date
What is the reason for your visit to Optima Foot & Ankle today?*
When did this start?*
Due to an injury?*

YesNo
Date of injury?

MonthDayYear
Date
Are there any other details about your injury that you would like us to know about?
List any other professional care for the problems you have indicated. (name, when seen, treatment)*
If you have pain, please let us know the location. Example: Left foot: inner arch, and outer ankle. Right foot: none, etc.
How long have you had the pain/discomfort?*

DaysWeeksMonthsYearsI have no pain
Please describe the pain.

SharpStabbingBurningPins/NeedlesPressureThrobbingRadiatingAche/DeepOther
When do you feel pain?

MorningWork/ActivityUneven groundSportsStartupEveningNightOther
Please list all prescription and non-prescription medications you currently use. Include the dose and how often you take them.*
Please check any current medical conditions.*

DiabetesHigh blood pressureHeart diseaseHeart attackStrokePeripheral vascular diseaseBlood clotsHigh cholesterolAsthmaCOPDHypothyroid diseaseGoutMuscle weakness: causeArthritisCramps in feet or legsFibromyalgiaLow back pain, sciaticaHeadachesNeuropathyMultiple sclerosisRheumatoid arthritisLupusParkinson’s diseaseHepatitisKidney diseaseLiver diseaseSkin conditionsStomach ulcers/acid refluxRaynaud’sAnxiety/DepressionCancerNone of the aboveOther
Do you have any other medical condition(s) that are not listed above?
List any allergies and the reaction(s) you have to medications.*
List any surgeries you have had in the past with approximate dates.
Surgery 1 (if applicable)
Date (Surgery 1)

MonthDayYear
Date
Surgery 2 (if applicable)
Date (Surgery 2)

MonthDayYear
Date
Surgery 3 (if applicable)
Date (Surgery 3)

MonthDayYear
Date
Have you ever had a reaction to anesthesia?*

YesNo
Have you had any hospitalizations in the last 5 years?*

YesNo
Social History
Are you a:*

Non smokerFormer smokerCurrent smokerHeavy smoker (20-39 cigarettes/day)Moderate smoker (10-19 cigarettes/day)Light smoker (1-9 cigarettes/day)Chewer of tobaccoOther
If you answered "I am a Former Smoker" please tell us when you quit smoking.
Do you drink alcohol?

YesNo
Do you use recreational drugs?*

YesNo
Do you exercise?

YesNo
Do you currently have:
Constitutional*

FeverChillsNauseaVomitingNight SweatsFatigueUnexpected Weight Loss/Weight GainNone of the AboveOther
Hematology*

Bruise easilyCold feetBlue toesVaricose veinsSwellingBlood ClotsSwollen GlandsNone of the aboveOther
Respiratory*

Shortness of BreathCoughNone of the aboveOther
Musculoskeletal*

Joint PainJoint swellingArthritisToe PainArch PainHeel PainAnkle PainFlat FeetBack PainLeg CrampsWeaknessPainful MassHistory of AmputationNone of the aboveOther
Neurologic*

Tingling/NumbnessBurning SensationWeaknessDifficulty WalkingSpasmRestless Leg SyndromeTremorsNone of the aboveOther
Dermatology*

RashAbnormal NailsIngrown NailsItchy FeetNon-healing WoundsDry SkinCracked SkinWartsPainful ScarBlistersCallous/CornsNone of the aboveOther
Head/Eyes/Ears/Nose/Throat*

HeadacheVision ChangesHearing LossCough/CongestionSore ThroatNose BleedRinging in EarsBalance DifficultiesNone of the aboveOther
Cardiovascular*

Chest PainIrregular Heart BeatLeg SwellingBlood ThinnersHistory of Cardiac SurgeryNone of the aboveOther
Gastrointestinal*

Heart BurnDiarrheaConstipationAbdominal PainNone of the aboveOther
Endocrinology*

Excessive SweatingExcessive ThirstExcessive UrinationCold IntoleranceHeat IntoleranceNone of the aboveOther
Family History
Father*

AliveDeceasedUnknown
Health - Father*

HypertensionHeart DiseaseStrokeCancerFoot DeformityDiabetesUnknownNo Current Health IssuesOther
Mother*

AliveDeceasedUnknown
Health - Mother*

HypertensionHeart DiseaseStrokeCancerFoot DeformityDiabetesUnknownNo Current Health IssuesOther
Sibling 1*

AliveDeceasedUnknownI do not have any siblings
Health - Sibling 1*

HypertensionHeart DiseaseStrokeCancerFoot DeformityDiabetesUnknownNo Current Health IssuesOther
If you'd like to list additional siblings, please list them here with their relevant info.
Questions specifically for patients with diabetes.
What is your most recent Hemoglobin A1c test result?
Name of the physician who is specifically caring for your diabetes?
When did you last see this physician for your diabetes care?

MonthDayYear
Date
Questions specifically for patients 65 and older.
Fall Risk (please check one):

No falls in the past yearOne fall with injury in the past yearTwo or more falls with injury in the past yearOne fall without injury in the past yearTwo or more falls without injury in the past year
Who should we contact in case of an emergency?
Emergency Contact*

First NameLast Name
Relationship (to ER Contact)
Phone Number (of ER Contact)*

Area CodePhone Number
Is there any additional information you would like us to know?
If yes, please add it here.
We highly value your privacy and security. All of your information will be encrypted when you click the "Submit" button for secure transmission.
Should be Empty:

New Patient Information Form

Please fill out this form completely.

Patient Information

Medical Insurance

Health History

List any surgeries you have had in the past with approximate dates.

Social History

Do you currently have:

Family History

Questions specifically for patients with diabetes.

Questions specifically for patients 65 and older.

Who should we contact in case of an emergency?

Is there any additional information you would like us to know?

We highly value your privacy and security. All of your information will be encrypted when you click the "Submit" button for secure transmission.