Intake and History Form
Name:
Date:
-
Month
-
Day
Year
Date
Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth:
-
Month
-
Day
Year
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:
-
Month
-
Day
Year
Date
Primary Providers Name:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
City or Zip Code:
Date Last seen:
-
Month
-
Day
Year
Date
Preferred Pharmacy
Name:
Phone Number:
Please enter a valid phone number.
Format: (000) 000-0000.
City or Zip Code:
Medical History
Select any of the following medical conditions you currently have:
None
Disease caused by 2019-nCoV
Leukemia
Anxiety disorder
Elevated blood pressure
Malignant lymphoma
Arthritis
End-stage renal disease
Malignant tumor of breast
Asthma
Epilepsy
Malignant tumor of colon
Atrial fibrillation
Gastroesophageal reflux disease
Malignant tumor of lung
Benign prostatic hyperplasia
H/O: hypertension
Malignant tumor of prostate
Cerebrovascular accident
Hearing loss
Radiation therapy treatment management
Chronic obstructive lung disease
Human immunodeficiency virus infection
Transplantation of bone marrow
Coronary arteriosclerosis
Hypercholesterolemia
Depressive disorder
Hypothyroidism
Diabetes mellitus
Inflammatory disease of liver
Other:
Surgical History
Have you had any of the following surgeries?
None
History of bilateral mastectomy
Pancreatectomy
Abdominoperineal resection
History of cholecystectomy
Kidney stone’s
Bilateral replacement of knee joints
History of colectomy
Portosystemic shunt operation
Biopsy of breast
History of liver excision
Prostatectomy
Biopsy of prostate
Percutaneous transluminal coronary angioplasty
Prosthetic arthroplasty of bilateral hips
Coronary artery bypass graft
Tissue graft heart valve replacement
Splenectomy
Entire transplanted kidney
History of total cystectomy
Surgical biopsy of skin
Excision of basal cell carcinoma
History of transurethral prostatectomy
Total nephrectomy
Excision of melanoma
Hysterectomy
Total orchidectomy
Excision of squamous cell carcinoma
Kidney biopsy
Total replacement of left hip joint
H/O: colostomy
Low anterior resection of rectum
Total replacement of left knee joint
H/O: tubal ligation
Lumpectomy of breast
Total replacement of right hip joint
History of appendectomy
Lumpectomy of left breast
Total replacement of right knee joint
History of bilateral mastectomy
Lumpectomy of right breast
Transplantation of heart
History of cholecystectomy
Mastectomy of left breast
Transplantation of liver
History of colectomy
Mastectomy of right breast
H/O: tubal ligation
Mechanical heart valve replacement
History of appendectomy
Oophorectomy
Other
Podiatry Foot/Ankle Disease History
Select any of the following medical conditions you currently have:
None
Fracture of bone
Peripheral venous insufficiency
Acquired cavus deformity of foot
Gangrenous disorder
Plantar fasciitis
Acquired pes planus
Hallux valgus
Primary gout
Amputation
Laceration - injury
Recurrent falls
Ankle ulcer
Localized infection
Rheumatoid arthritis
Bone tumor
Neoplasm of soft tissue
Rupture of Achilles tendon
Chronic pain
Neuroma of foot
Sprain of lateral ligament of ankle joint
Deep venous thrombosis
Osteoarthritis Ulcer of foot
Dystrophia unguium
Peripheral nerve disease
Foreign body
Peripheral vascular disease
Shoe Size:
Shoe Size:
Shoe Width:
Narrow
Medium
Wide
Extra Wide
Medications
List all current medications:
Allergies
List all allergies:
Social History
Smoking Status:
Current smoker
Current someday smoker
Former smoker
Never smoker
Unknown if ever smoked
Start Smoking:
-
Month
-
Day
Year
Date
Start Smoking:
-
Month
-
Day
Year
Date
Number of Packs Per Day:
Number of Packs Per Day:
Alcohol Intake:
None
1 or less per day
1-2 per day
3 or more per day
Driving Status:
Drives in the Daytime
Drives at Night
How often do you exercise?
Unspecified Several times a day
Once a day
A few times a week
A few times a month
Never
Other
What is your caffeine use?
Unspecified
Several times a day
Once a day
A few times a week
A few times a month
Never
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
Submit
Should be Empty: