Welcome to Practice
PATIENT INFORMATION
Patient Name
First Name
MI
Last Name
Gender
Male
Female
Marital Status
Single
Married
Widowed
Separated
Spouse / Partner Name
Spouse Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Do you have children?
Yes
No
If yes, Ages
Patient Home Street Address
Street Address
Street Address Line 2
City
State
Zip Code
PO Mailing Address (if applicable)
Street Address
Street Address Line 2
City
State
Zip Code
Home Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Cell Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Patient Email Address
example@example.com
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age
Social Security Number
Height
Weight
Shoe Size
Patient Occupation
Employer Name
Employer Address
Employer Phone
Please enter a valid phone number.
Format: (000) 000-0000.
BEST CONTACT INFORMATION
Best Contact Information
Home Phone
Cell Phone
Work
Email
If patient is a minor – Name of parent or guardian
Address of parent or guardian
Parent / Guardian Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
Emergency Contact Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship
PAYMENT AND INSURANCE INFORMATION
Please present your insurance card and driver’s license upon arrival
Check here if no health insurance
Full Name of Insured
First Name
Last Name
Relationship to Patient
Insured SS#
Insured Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Insured Employer
Employer Address
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Co-Pay Amount ($)
Deductible Amount ($)
Payment today will be made by
Cash
Check
Visa
Master Card
American Express
Discover
My insurance requires a referral from my PCP before I see a specialist
Yes
No
REFERRAL INFORMATION
We appreciate your referrals! Who may we thank for referring you to our office?
Name
Address
Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Is this person your:
PCP
Other Specialist
Family Member
Friend
Other Referral Sources (check all that apply)
Internet Search
Phone Book
Our Practice Website
Newspaper Ad
Saw our sign
Insurance Plan or Website
Other
If applicable, please specify (website name, insurance name, etc.)
Back
Next
PODIATRIC HISTORY
Have you ever been to a podiatrist before?
Yes
No
What is your chief foot complaint for which you came to be treated?
When did it begin?
Did you receive treatment for this condition?
Yes
No
If yes, what type of treatment?
Select the degree of pain you are currently experiencing
Minimal
1
2
3
4
5
6
7
8
9
Severe
10
1 is Minimal, 10 is Severe
Have you ever had any of the following foot conditions? Please check all that apply
Ankle Instability
Arthritis
Back Pain
Blisters
Bone Spurs
Bunions
Burning Feet
Corns/Calluses
Diabetic Evaluation
Flat Feet
Fracture
Fungal Infections (skin/nail)
Gout
Hammertoes
Heel Pain
Hip Pain
Infections
Ingrown Toenails
Intoe-Out toe walking
Joint Pain
Knee Pain
Limb Length Discrepancy
Neuromas
Numbness or tingling in foot or toes
Plantar Fasciitis
Postural Fatigue
Pronation
Shin Splints
Sprains
Sweating/Odor
Tendonitis
Tired feet
Ulcers
Warts
Other
MEDICAL HISTORY
Have you ever been treated for any of the following conditions?
Select the family side only if the condition applies to you.
Rows
Family Side
Acid Reflux
Mother side (M)
Father side (F)
Both
Not applicable
Anemia
Mother side (M)
Father side (F)
Both
Not applicable
Arthritis
Mother side (M)
Father side (F)
Both
Not applicable
Asthma
Mother side (M)
Father side (F)
Both
Not applicable
Bleeding Disorders
Mother side (M)
Father side (F)
Both
Not applicable
Cancer
Mother side (M)
Father side (F)
Both
Not applicable
Depression
Mother side (M)
Father side (F)
Both
Not applicable
Diabetes
Mother side (M)
Father side (F)
Both
Not applicable
Epilepsy
Mother side (M)
Father side (F)
Both
Not applicable
Fatigue
Mother side (M)
Father side (F)
Both
Not applicable
Fibromyalgia
Mother side (M)
Father side (F)
Both
Not applicable
Headaches
Mother side (M)
Father side (F)
Both
Not applicable
Heart Condition
Mother side (M)
Father side (F)
Both
Not applicable
Hepatitis
Mother side (M)
Father side (F)
Both
Not applicable
High Cholesterol
Mother side (M)
Father side (F)
Both
Not applicable
HIV / AIDS
Mother side (M)
Father side (F)
Both
Not applicable
Hypertension
Mother side (M)
Father side (F)
Both
Not applicable
Hyperthyroidism
Mother side (M)
Father side (F)
Both
Not applicable
Hypothyroidism
Mother side (M)
Father side (F)
Both
Not applicable
Irritable Bowel Syndrome
Mother side (M)
Father side (F)
Both
Not applicable
Kidney Problems
Mother side (M)
Father side (F)
Both
Not applicable
Liver Disease
Mother side (M)
Father side (F)
Both
Not applicable
Low Blood Pressure
Mother side (M)
Father side (F)
Both
Not applicable
Nervous Disorder
Mother side (M)
Father side (F)
Both
Not applicable
Muscle or Joint Pain
Mother side (M)
Father side (F)
Both
Not applicable
Peripheral Arterial Disease
Mother side (M)
Father side (F)
Both
Not applicable
Parkinson's Disease
Mother side (M)
Father side (F)
Both
Not applicable
Phlebitis
Mother side (M)
Father side (F)
Both
Not applicable
Poor Circulation
Mother side (M)
Father side (F)
Both
Not applicable
Respiratory Disease
Mother side (M)
Father side (F)
Both
Not applicable
Rheumatic Fever
Mother side (M)
Father side (F)
Both
Not applicable
Shortness of Breath
Mother side (M)
Father side (F)
Both
Not applicable
Seizure Disorders
Mother side (M)
Father side (F)
Both
Not applicable
Stomach Ulcers
Mother side (M)
Father side (F)
Both
Not applicable
Stroke
Mother side (M)
Father side (F)
Both
Not applicable
Varicose Veins
Mother side (M)
Father side (F)
Both
Not applicable
MEDICATIONS
Are you currently on Blood Thinners?
Yes
No
Please list your current medications(You may also provide a printed list)
Do you currently use Cigarettes or Tobacco?
Yes
No
Quit
If yes, for how long?
How many packs per day?
If quit, when?
Alcohol use?
Yes
No
If yes, quantity
How often?
Daily
Weekly
SURGERIES
Please list all surgeries
Name of MD / Family Physician
Address
Date of Last Visit
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
ALLERGIES
Have you ever had any adverse side effects or allergies to:
Rows
Yes
No
Adhesive Tape
Anticoagulants
Anti-inflammatory Meds
Aspirin
Codeine
Cortisone
Iodine
Latex
Metal / Jewelry
Novacaine
Peanuts
Penicillin
Seafood
Other antibiotics
Other pain medication
If other, please explain
SIGNATURE ON FILE AND PERMISSION TO TREAT
I understand that the information provided on this form is true and correct to the best of my knowledge.
I request that payments of authorized benefits be made on my behalf for any services furnished by Associated Podiatry.
I authorize any holder of information about me to release any information needed to determine these benefits or the benefits payable to related services to the insurance agent.
I recognize my financial obligation of any coinsurance, co-pays or deductibles and non-covered services that may be required.
I hereby give permission to Associated Podiatry and any qualified staff to evaluate, diagnose and treat my foot and/or ankle condition as may be deemed necessary.
Patient or Authorized Signature
If not patient, state relationship
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Should be Empty: