LOCAL FOOT DOC WALDEMAR MAJDANSKI DPM, PCFOOT AND ANKLE CENTER OF NY AND NJ, LLC
PATIENT BACKGROUND
SS#
DATE:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
NAME:
First Name
Last Name
EMAIL:
example@example.com
ADDRESS:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PHONE#
Format: (000) 000-0000.
AGE:
DATE OF BIRTH:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SEX:
MARITAL STATUS:
S
M
W
D
HEIGHT:
WEIGHT:
SHOE SIZE:
Guardians name if patient is a minor:
Street Address Line 2
City
State / Province
Postal / Zip Code
Guardians address if different from above:
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone# (Guardian)
Format: (000) 000-0000.
Occupation:
Business Address:
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone# (Business)
Format: (000) 000-0000.
Occ. of Spouse/Parent:
Business Address (Spouse/Parent):
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone# (Spouse/Parent Business)
Format: (000) 000-0000.
By whom were you referred??
INSURANCE:
Medicare
Medicaid
Union
Private Insurance
Workers Comp
No Fault
Name of Insurance Company:
ID#
Please tell us as well as you can, the main problem as well as other problems, that brought you to the office:
Please answer the following questions, so we may better know you and your medical background.
What Allergies do you have?
Are you in
good health
fair health
poor health
Do you have a primary doctor?
Yes
No
Are you pregnant?
Yes
No
Do you smoke?
Yes
No
Do you drink alcohol?
Yes
No
Primary doctor name and address:
What medications are you taking?
Past surgeries?
Medical problems: Diabetes/High Blood Pressure/High Cholesterol/Asthma/Cancer/Gout/Heart Trouble/Anemia/Stroke/Kidney Problems
Diabetes
High Blood Pressure
High Cholesterol
Asthma
Cancer
Gout
Heart Trouble
Anemia
Stroke
Kidney Problems
Other medical problems:
What sports do you participate in?
Thank you. This little extra effort on your part helps us help you.
AUTHORIZATION AND CONSENT FOR TREATMENT
I hereby authorize Dr. Majdanski/Khaimov and Associates to treat me for correction and alleviation of the above mentioned and future complaints and conditions.
Signed:
Date:
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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