Clone of AdvancedFootTexas - Patient Paperwork3

Fill Out Completely & Submit (5 Sections)

Please take your time & include as much information as you have available as this is to become part of your Confidential Medical Record.

Date of Appointment:*

MonthDayYear
Patient's Name:*

First NameMiddle NameLast Name
Patient's Date of Birth:*

MonthDayYear
YesNo
MotherFather
Mother's Name:

First NameMiddle NameLast Name
Father's Name:

First NameMiddle NameLast Name
Mother's Date of Birth:

MonthDayYear
Father's Date of Birth:

MonthDayYear
SingleMarriedDivorcedSeparatedWidowed
SingleMarriedDivorcedSeparatedWidowed
Mother's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Father's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Mother's Home Phone Number:

Area CodePhone Number
Father's Home Phone Number:

Area CodePhone Number
Mother's Work Phone Number:

Area CodePhone Number
Father's Work Phone Number:

Area CodePhone Number
Mother's Cell Phone Number:

Area CodePhone Number
Father's Cell Phone Number:

Area CodePhone Number
Mother's Email Address:
Father's Email Address:
Mother's Employer:
Father's Employer:
Mother's Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Father's Employer's Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
MaleFemale
SingleMarriedDivorcedSeparatedWidowed
Home Phone Number:*

Area CodePhone Number
Work Phone Number:

Area CodePhone Number
Cell Phone Number:

Area CodePhone Number
E-mail Address:
Spouse's Name:

First NameLast Name
Spouse's Date of Birth:

MonthDayYear
Spouse's Employer:
Patient's Physical Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
YesNo
Patient's Mailing Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Health Insurance Company:*
If you are uninsured type "None" into this field.
Subscriber ID
Me - The PatientSomeone other than me
Policy Holder's Name:

First NameLast Name
Policy Holder's Date of Birth:

MonthDayYear
YesNoRetiredOther
Occupation:
Number of Years at Occupation:
Address of Employer:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Found You Online/WebsiteReferred by FriendReferred by Other PatientReferred by Primary DoctorInsurance Provider WebsiteDrove by OfficeOther
Pharmacy:
Pharmacy Phone Number:

Area CodePhone Number
Provide Details if possible:

What and where is your primary foot or ankle problem?*
When did you first notice the problem?*
Have you ever had treatment for this problem, and by whom?*
What is your Weight?*
approximate # in pounds
What is your Height?*

FeetInches
What is your Shoe Size?*

Primary Physician Info:

***ONLY REQUIRED FOR MEDICARE PATIENTS***
YesNo
Name of Primary Care Physician:

First NameLast Name
Speciality:
Office Phone Number:

Area CodePhone Number
Office Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
As NeededRegularly for Treatment
Date of Last Visit?

MonthDayYear

Has any blood relative ever had: Place an 'X' in any appropriate "Yes" boxes.

Rows	Yes	If Yes, who? (father or mother)
Adopted
Alcoholism
Alzheimers dementia
Bleeding Tendancies
BP+-Hypertension
Cancer
Diabetes
Foot Problems (ie. bunions)
Gout
Heart Disease
Hepatitis/Liver Disease
High Blood Pressure
Kidney Disease
Neurological Disease
Plantar fasciitis
Rheumatoid Arthritis
Stroke
Thyroid Disease
Tuberculosis

Social History: Please Fill in boxes with an 'X' if they apply and fill in what type.

Rows	Never	Rarely	Occasionally	Daily
Alcohol
Aspirin
Coffee or Tea
Sleeping Pills
Tobacco
Tranquilizers

Should be Empty:

Fill Out Completely & Submit (5 Sections)

Primary Physician Info: