prestigeanklefoot.com - Patient Intake Form

Intake and History Form
Name:
Date:

MonthDayYear
Date
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth:

MonthDayYear
Date
Gender:
Phone Number (day):
Please enter a valid phone number.Format: (000) 000-0000.
Email Address:
example@example.com
Emergency Contact:
Preferred Language:
Race:
Ethnic Group:
Insurance (Primary)
Policy ID:
Policy Holder:
Insurance (Secondary)
Policy ID:
Policy Holder:
Referring Provider & Primary Provider
Referring Providers Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
City or Zip Code:
Date Last seen:

MonthDayYear
Date
Primary Providers Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
City or Zip Code:
Date Last seen:

MonthDayYear
Date
Preferred Pharmacy
Name:
Phone Number:
Please enter a valid phone number.Format: (000) 000-0000.
City or Zip Code:
Medical History
NoneDisease caused by 2019-nCoVLeukemiaAnxiety disorderElevated blood pressureMalignant lymphomaArthritisEnd-stage renal diseaseMalignant tumor of breastAsthmaEpilepsyMalignant tumor of colonAtrial fibrillationGastroesophageal reflux diseaseMalignant tumor of lungBenign prostatic hyperplasiaH/O: hypertensionMalignant tumor of prostateCerebrovascular accidentHearing lossRadiation therapy treatment managementChronic obstructive lung diseaseHuman immunodeficiency virus infectionTransplantation of bone marrowCoronary arteriosclerosisHypercholesterolemiaDepressive disorderHypothyroidismDiabetes mellitusInflammatory disease of liverOther:
Surgical History
NoneHistory of bilateral mastectomyPancreatectomyAbdominoperineal resectionHistory of cholecystectomyKidney stone’sBilateral replacement of knee jointsHistory of colectomyPortosystemic shunt operationBiopsy of breastHistory of liver excisionProstatectomyBiopsy of prostatePercutaneous transluminal coronary angioplastyProsthetic arthroplasty of bilateral hipsCoronary artery bypass graftTissue graft heart valve replacementSplenectomyEntire transplanted kidneyHistory of total cystectomySurgical biopsy of skinExcision of basal cell carcinomaHistory of transurethral prostatectomyTotal nephrectomyExcision of melanomaHysterectomyTotal orchidectomyExcision of squamous cell carcinomaKidney biopsyTotal replacement of left hip jointH/O: colostomyLow anterior resection of rectumTotal replacement of left knee jointH/O: tubal ligationLumpectomy of breastTotal replacement of right hip jointHistory of appendectomyLumpectomy of left breastTotal replacement of right knee jointHistory of bilateral mastectomyLumpectomy of right breastTransplantation of heartHistory of cholecystectomyMastectomy of left breastTransplantation of liverHistory of colectomyMastectomy of right breastH/O: tubal ligationMechanical heart valve replacementHistory of appendectomyOophorectomyOther
Podiatry Foot/Ankle Disease History
NoneFracture of bonePeripheral venous insufficiencyAcquired cavus deformity of footGangrenous disorderPlantar fasciitisAcquired pes planusHallux valgusPrimary goutAmputationLaceration - injuryRecurrent fallsAnkle ulcerLocalized infectionRheumatoid arthritisBone tumorNeoplasm of soft tissueRupture of Achilles tendonChronic painNeuroma of footSprain of lateral ligament of ankle jointDeep venous thrombosisOsteoarthritis Ulcer of footDystrophia unguiumPeripheral nerve diseaseForeign bodyPeripheral vascular disease
Shoe Size:
Shoe Size:
NarrowMediumWideExtra Wide
Medications
List all current medications:
Allergies
List all allergies:
Social History
Current smokerCurrent someday smokerFormer smokerNever smokerUnknown if ever smoked
Start Smoking:

MonthDayYear
Date
Start Smoking:

MonthDayYear
Date
Number of Packs Per Day:
Number of Packs Per Day:
None1 or less per day1-2 per day3 or more per day
Drives in the DaytimeDrives at Night
Unspecified Several times a dayOnce a dayA few times a weekA few times a monthNeverOther
UnspecifiedSeveral times a dayOnce a dayA few times a weekA few times a monthNever
Family History
Please include only first-degree relatives:
Review of Systems

Please check yes or no for the following:

Symptom

Rows	Yes	No
Musculoskeletal – Joint Pain
Musculoskeletal – Joint Swelling
Musculoskeletal – Joint Stiffness
Musculoskeletal – Unsteady Gait
Neurological - Numbness
Neurological - Tingling
Neurological - Dizziness
Neurological - Headaches
Neurological - Tremors
Neurological - Fatigue
Integumentary - Rash
Integumentary - Itching
Integumentary - Rash
Integumentary – Scarring / Keloids

Alerts

Please check yes or no for the following:

Symptom

Rows	Yes	No
Blood Thinners
Pacemaker
Defibrillator
Allergic to Latex
Allergic to Adhesive
Under Pain Management
Rheumatoid Arthritis

Should be Empty:

Intake and History Form

Referring Provider & Primary Provider

Preferred Pharmacy

Medical History

Surgical History

Podiatry Foot/Ankle Disease History

Shoe Size:

Medications

Allergies

Social History

Family History

Review of Systems

Alerts