montrosefootdoctor.com - Patient Information Sheet

Patient Information Sheet

San Juan Foot & Ankle Center
Welcome to our office…

Please take a few minutes to complete the following form, as thoroughly as possible. Thank you.
Patient Name:

First NameLast Name
Social Security #:
DOB:

MonthDayYear
Date
Age:
Sex:
Marital Status:
Email:
example@example.com
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number: (Home)
Please enter a valid phone number.
Phone Number: (Work)
Please enter a valid phone number.
Phone Number: (Other/Cell#)
Please enter a valid phone number.
Employer
Occupation
Hours on feet
Primary Care Physician
Preferred Pharmacy
How did you learn of SAN JUAN FOOT AND ANKLE * please list name
DoctorFriendRelativeInsurance ManualInternetOther
Please list site
Insurance Information
Medical Insurance:

YesNo
A photo copy of your medical card(s) will be taken to obtain all necessary policy numbers & Photo ID

Parent/ Guardian/ Spouse Information
Name

First NameLast Name
Relationship Parent Guardian Spouse
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Numbers: Home#
Please enter a valid phone number.
Phone Numbers: Work#
Please enter a valid phone number.
Phone Numbers: Other/Cell#
Please enter a valid phone number.
PLEASE READ CAREFULLY

ANY UNPAID MONIES OWED FOR SERVICES RENDERED MAY BE REFERRED TO A THIRD PARTY COLLECTION AGENCY. THE AGENCY WE USE CHARGES 35% OF THE UNPAID BALANCE, DUE AT THE TIME IT IS TURNED INTO THEM. THOSE FEES BECOME YOUR RESPONSIBILITY, AS WELL AS THE PRINCIPLE BALANCE OWED. IN ADDITION TO COLLECTION COSTS AND INTREST, YOU WILL ALSO BE LIABLE FOR ALL ATTORNEY’S FEES AND COURT COSTS ASSOCIATED WITH LITIGATION RESULTING FROM NON-PAYMENT. (INITIAL)

ALL PROFESSIONAL SERVICES RENDERED ARE CHARGED TO THE PATIENT. NECESSARY FORMS WILL BE COMPLETE TO EPEDITE INSURANCE CLAIMS. THE PATIENT IS RESPONSIBLE FOR ALL FEES, REGARDLESS OF INSURANCE COVERAGE. IT IS CUSTOMARY TO PAY FOR SERVICES WHEN RENDERED, UNLESS ARRANGEMENTS ARE MADE IN ADVANCE. ALL COPAYS AND DEDUCTIBLES ARE DUE AT THE TIME OF SERVICE. OFFICE VISITS AND PROCEDURES BILLED TO MY INSURANCE COMPANY AND NOT PAID WITHIN 60 DAYS BECOME THE RESPONSIBILITY OF THE PATIENT/GAURDIAN AT AN INTEREST RATE NOT EXCEED 19% ANNUM. PATIENTS WILL BE RESPONSIBLE FOR ANY AND ALL FEES ASSOCIATED WITH THE COLLECTION OF OUTSTANDING ACCOUNTS. I AUTHORIZE S.J.F.A.C. TO FURNISH INFORMATION TO INSURANCE CARRIERS CONCERNING MY ILLNESS AND TREATMENTS. I HEREBY ASSIGN TO THE DOCTORS ALL PAYMENTS FOR MEDICAL SERVICES RENDERED TO MY DEPENEDENTS OR MYSELF. I UNDERSTAND THAT I MAY BE RESPONSIBLE FOR ANY AMOUNT NOT COVERED BY INSURANCE. THE PATIENT WILL BE CHARGED $25 ($75 NEW PATIENT VISITS) FOR MISSED APPOINTMENTS OR THOSE NOT CANCELLED WITHIN 24 HOURS, WITH CONSIDERATION OF CIRCUMSTANCES SUCH AS EMERGENCIES OR SICKNESS. THIS CHARGE IS NOT COVERED BY ANY INSURNACE PLAN. I AUTHORIZE TREATMENT FOR MY FOOT/ANKLE AND RELATED CONDITIONS.

I have received the Confidentially Agreement (HIPAA), as well as the payment agreement, and agree to comply with all its terms.
Patient’s Signature:

Clear
Today’s Date:

MonthDayYear
Date
Draw on Image
Please describe the condition(s) in which you are here for today:
Have you had this problem before?
What solved it?
When did this problem start?
What caused the problem? Select all that apply

TraumaOver useNew activityIncreased activityNew shoesOther:
How bad is your pain on a scale from 1-10?

1

2

3

4

5

6

7

8

9

10

1 is Least, 10 is Worst
What aggravates your problem(s)? Select all that apply

WalkingStandingDirect pressureShoesSleepingStanding after restWorsens with activityOther:
Does anything alleviate your pain?

MedicationsIceElevationRestNarcoticsAnti-inflammatoriesShoes,OrthoticsOther:
Have you ever had medical treatment for this problem before? When/where/what?
Are there any associated symptoms with your problem? Select all that apply

RednessSwellingBruisingItching /discolorationDrainageRashOther:
Why does your problem concern you?
Please check the following if you have EVER experienced or had problems with:

Heart AttackHigh Blood PressureGoutParkinson’sHeart MurmurMultiple SclerosisCholesterolCancerCOPDOsteoarthritisGastric RefluxBlood ClotCirrhosisRheumatoid ArthritisBirth DefectGlaucomaHepatitisDiabetesChronic Back PainKidneysAIDS/HIVAnxietySkin DiseaseRheumatic FeverLiverDepressionArrhythmiaStrokeAsthmaSeizuresHypothyroidismUlcersOther:
Cancer (type)
Blood Clot (where)
Hepatitis (Please specify)
Kidneys (Please specify)
Ulcers (Where)
Height:
Weight:
List ALL medications and supplements you are CURRENTLY taking:
List ALL allergies and reactions to medications:
List ALL surgeries you have had, date of, complications, and any reaction to anesthetics:
How many cigarettes do you/did you smoke per day?
When did you start and/or stop?
How many alcohol drinks do you/did you have per week?
Do you/did you use any non-prescriptive drugs or IV drugs?
IMMEDIATE Family History of: (List who and what, and are they deceased from the condition)
Cancer:
High Blood Pressure:
Heart Condition:
Diabetes:
Foot or Leg Deformities:
Muscle or Bone:
Please check mark any of the following conditions YOU have RECENTLY experienced:
CON:

FeverChillsNauseaVomitingWeight lossWeight gain
Integ:

LumpsSoresRashes
Head:

DizzinessEye sight changesHeadachesProblem SwallowingRinging ears
Resp:

Problems breathingPneumoniaAsthma
CV:

Chest painChest tightnessHeart palpitationsHeart murmur
GI:

Abdominal crampingBloody stoolsDiarrheaStomach burning
GU:

DischargePain with urination
M-skel:

Broken bonesCrampingLimb deformity
Neuro:

Loss of ConsciousnessLoss of use of any limbBlackoutsSeizures
Endo:

Night sweatsExcessive thirstFreq. night urinationExcessive hunger
Heme:

Excessive bleedingExcessive bruising
Psych:

DepressionAnxietyNervousness
Is there anything else the Doctor should know about your or your medical history?
Should be Empty:

Patient Information Sheet

Insurance Information