New Patient Form

New Patient Information Form

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

Month Day Year
Date
Gender *

Male Female Other
Mailing Address *

Street Address

Street Address Line 2

City State / Province

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

Area Code Phone Number
Secondary Phone #

Area Code Phone Number
Social Security Number
Occupation *
Martial Status *

Married Separated Divorced Single Widowed Partner Other
Preferred Language *

English Spanish Other
Race *

American Indian or Alaska Native Asian Native Hawaiian Black or African American White Hispanic Other Pacific Islander Other Race Unreported/Refused to Report
Ethnicity *

Hispanic or Latino NOT Hispanic or Latino Unreported/Refused to Report
Medical Insurance
Do you have Medical Insurance? If no, please continue to the next section "Health History".

Yes No
PRIMARY Medical Insurance Name
PRIMARY Medical Insurance - Subscriber ID #
PRIMARY Medical Insurance - Group #
PRIMARY Medical Insurance - Subscriber Name

First Name Last Name
PRIMARY Medical Insurance - Subscriber Date of Birth

Month Day Year
Date
PRIMARY Medical Insurance - Relation to Patient

Self Spouse Parent Other
Do you have a SECONDARY Medical Insurance Plan?

Yes No
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 Name Last Name
SECONDARY Medical Insurance - Subscriber Date of Birth (If you answered YES)

Month Day Year
Date
SECONDARY Medical Insurance - Relation to Patient (If you answered YES)

Self Spouse Parent Other
Health History
Full Name *

First Name Last Name
Date of Birth *

Month Day Year
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? *

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

Yes No
Date of injury?

Month Day Year
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? *

Days Weeks Months Years I have no pain
Please describe the pain.

Sharp Stabbing Burning Pins/Needles Pressure Throbbing Radiating Ache/Deep
When do you feel pain?

Morning Work/Activity Uneven ground Sports Startup Evening Night
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. *

Diabetes High blood pressure Heart disease Heart attack Stroke Peripheral vascular disease Blood clots High cholesterol Asthma COPD Hypothyroid disease Gout Muscle weakness: cause Arthritis Cramps in feet or legs Fibromyalgia Low back pain, sciatica Headaches Neuropathy Multiple sclerosis Rheumatoid arthritis Lupus Parkinson’s disease Hepatitis Kidney disease Liver disease Skin conditions Stomach ulcers/acid reflux Raynaud’s Anxiety/Depression Cancer None of the above
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)

Month Day Year
Date
Surgery 2 (if applicable)
Date (Surgery 2)

Month Day Year
Date
Surgery 3 (if applicable)
Date (Surgery 3)

Month Day Year
Date
Have you ever had a reaction to anesthesia? *

Yes No
Have you had any hospitalizations in the last 5 years? *

Yes No
Social History
Are you a: *

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

Yes No
Do you use recreational drugs? *

Yes No
Do you exercise?

Yes No
Do you currently have:
Constitutional *

Fever Chills Nausea Vomiting Night Sweats Fatigue Unexpected Weight Loss/Weight Gain None of the Above
Hematology *

Bruise easily Cold feet Blue toes Varicose veins Swelling Blood Clots Swollen Glands None of the above
Respiratory *

Shortness of Breath Cough None of the above
Musculoskeletal *

Joint Pain Joint swelling Arthritis Toe Pain Arch Pain Heel Pain Ankle Pain Flat Feet Back Pain Leg Cramps Weakness Painful Mass History of Amputation None of the above
Neurologic *

Tingling/Numbness Burning Sensation Weakness Difficulty Walking Spasm Restless Leg Syndrome Tremors None of the above
Dermatology *

Rash Abnormal Nails Ingrown Nails Itchy Feet Non-healing Wounds Dry Skin Cracked Skin Warts Painful Scar Blisters Callous/Corns None of the above
Head/Eyes/Ears/Nose/Throat *

Headache Vision Changes Hearing Loss Cough/Congestion Sore Throat Nose Bleed Ringing in Ears Balance Difficulties None of the above
Cardiovascular *

Chest Pain Irregular Heart Beat Leg Swelling Blood Thinners History of Cardiac Surgery None of the above
Gastrointestinal *

Heart Burn Diarrhea Constipation Abdominal Pain None of the above
Endocrinology *

Excessive Sweating Excessive Thirst Excessive Urination Cold Intolerance Heat Intolerance None of the above
Family History
Father *

Alive Deceased Unknown
Health - Father *

Hypertension Heart Disease Stroke Cancer Foot Deformity Diabetes Unknown No Current Health Issues
Mother *

Alive Deceased Unknown
Health - Mother *

Hypertension Heart Disease Stroke Cancer Foot Deformity Diabetes Unknown No Current Health Issues
Sibling 1 *

Alive Deceased Unknown I do not have any siblings
Health - Sibling 1 *

Hypertension Heart Disease Stroke Cancer Foot Deformity Diabetes Unknown No Current Health Issues
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?

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

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

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

Area Code Phone 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.