ocfootdoctor.com - Medical History Form

Medical History
This secure form consists of 3 parts and will take approximately 5 minutes to complete. Information on this page is protected with up to 256-bit encryption. We do NOT require your Social Security Number.

Enter "N/A" if question is not applicable
1. Patient Information
Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email:
example@example.com
Mobile #:*
Please enter a valid phone number.
Sex:

MaleFemale
Marital Status:

MarriedSingleWidowedMinorSeparatedDivorcedPartnered
Employer / School:
Employer / School Phone:
Please enter a valid phone number.
In case of emergency contact Name & address:
2. Insurance
Who is the primary on this account:*

SelfOther
Date of birth of the primary:*

MonthDayYear
Date
Relationship to patient:

SelfOther
Insurance Company:*
Group Number:
Subscriber ID:*
Insurance Phone Number:
Please enter a valid phone number.
Is patient covered by other insurance:*

YesNo
3. Podiatric and Medical History
Main reason for visiting us (e.g. foot, ankle, knee...):*
Have you been to a Podiatrist(s) before:*

YesNo
Please list name(s)specify:
Cigarette / Tobacco use:*

YesNo
Please specify years smoked:
Is there any personal or family history of diabetes:*

YesNo

Please indicate which foot problems you now have or have had in the past:*

	Yes	No
Ankle Pain:
Athlete's Foot:
Bunions:
Corns & Calluses:
Cramps or Numbness in Feet or Legs:
Flat Feet:
Foot or Leg Cramps:
Heel Pain:
Ingrown Toenails:
Plantar Warts:

Please choose "YES" or "NO" to indicate if you have had any of the followings:*

	Yes	No
AIDS/HIV:
Allergies to Anesthetics:
Allergies to Medicine or Drugs:
Anemia:
Angina:
Arthritis:
Artificial Heart Valves or Joints:
Asthma:
Back Problems:
Bleeding Disorders:
Cancer:
Chemical Dependency:
Chest Pain:
Chronic Diarrhea:
Weight Loss, Unexplained:
Special Diet:
Stroke:
Swelling in Ankles, Feet:
Swollen Neck Glands:
Tired Feet:
Tuberculosis:
Ulcers:
Varicose Veins:
Venereal Disease:
Hepatitis or Jaundice:
High Blood Pressure:
Kidney Problems:
Liver Disease:
Low Blood Pressure:
Neuropathy:
Phlebitis:
Psychiatric Care:
Radiation Treatment:
Rash:
Respiratory Disease:
Rheumatic Fever:
Shortness of Breath:
Sinus Problems:
Circulatory Problems:
Diabetes:
Ear Problems:
Epilepsy:
Eye Problems:
Fainting:
Gout:
Headaches:
Heart Disease:
Hemophilia:

Other:
Surgeries you have had:*
Hospitalization other than for the surgeries listed:*
Family physician Name & last date visited:*
Are you now, or have you been, under any other doctor's care for any reason over the past two years?

YesNo
Please explain:
Medications? Include prescriptions, over-the-counter medications and vitamins:*
Pharmacy Name(s):*
Pharmacy Phone(s):*
Do you take oral contraceptives:

YesNo
Allergies: (if N/A -- Select "Other:" and enter N/A)*

Adhesive/Tape:Local Anesthetics:Anticoagulant Therapy:Novocaine:Aspirin:Penicillin:Codeine:Seafoods:Demerol:Sulfa:Iodine:Other:
Treatment Consent
I hereby consent and give my permission to the doctor (and the doctor's assistants or designated replacement) to administer and perform such procedures upon me as the doctor seems necessary.
Should be Empty:

Medical History