Please print
Last name_________________________First
Name______________M.I.________________
Street Address _______________________________________________________________
City_________________________________State______ Zip Code_____________________
Home Phone (___)_______-________ Date of Birth______/______/______
Age:_________
Social Security Number:_______-_______-_______ Sex:
M F Martial Status:
Name of Employer:_________________________ Occupation:____________
Business Phone: (_______)__________-__________ Ext:________
Medical Doctor (PCP):____________________________________________
PCP Address:___________________________________________________
PCP Phone: (_______)__________-__________ Date last seen:________________
Person Responsible for Paying the Bills:_____________________________
Relationship to patient:___________________________________________
Address (if different):_____________________________________________
Spouse or guardian's name:_______________________________________
Name of their employer:__________________________________________
Business address:______________________________________________
Business phone:(_______)__________-__________Ext:__________
Health Insurance Information:
| Primary
insurance company |
Secondary
insurance company |
Name______________________________________
|
2.___________________________ |
Address____________________________________
|
2.___________________________ |
Telephone number(_______)_______-___________
|
2.___________________________ |
Member ID number___________________________ |
2.___________________________ |
Group or account number_____________________ |
2.___________________________ |
| Name of subscriber_________________________ |
2.___________________________ |
| Subscriber's date of birth_________________________ |
2.___________________________ |
Relationship to patient________________________ |
2.___________________________ |
Is a referral required?_________________________ |
2.___________________________ |
|
|
Medical Information
Name of pharmacy:_______________________________ Phone:(______)______-_________
Describe your foot problem:_______________________________________________________
_____________________________________________________________________________
Duration of problem?______________________________
Any past injuries of the feet or ankles?___________________________________
Any past surgeries of the feet or
ankles?_________________________________
Shoe size ______ Current Weight ______
Height ______
Allergies:
| ___Penicillin |
___Sulfa |
___Tetracycline |
___ibuprofen
(Advil/Motrin) |
| ___Tape |
___Betadine (iodine) |
___Codeine |
___Other
antibiotics_______________________ |
| ___Novocain |
___Lidocaine |
___Aspirin |
___Any
medicines_________________________ |
General information:
Do you have diabetes? Yes ____ No _____
If yes, do you use insulin? Yes___ No ____ # of units __
Do you have any serious illnesses?___________________________________________________________________
___________________________________________________________________________
Have you had any major surgeries?______________________________________________
___________________________________________________________________________
Are you under the care of a physician? Yes ___ No ___
If yes for what condition (s) ____________________________________________________
What medications do you take and dosage?
_____________________________________
__________________________________________________________________________
__________________________________________________________________________
Check any of the following you
currently or in the past have experienced problems with:
|
( ) Heart |
( ) Asthma |
( ) Skin |
|
( ) Poor Circulation |
( ) Stomach Ulcers |
( ) Gout |
|
( ) Arthritis |
( ) Hormones |
( ) Tuberculosis |
|
( ) Kidneys |
( ) Anemia |
( ) Rheumatic Fever |
|
( ) Lungs |
( ) Bladder |
( ) Liver |
|
( ) Cancer |
( ) High Blood Pressure |
( ) Frequent Infections |
|
( ) Poor Healing |
( ) Intestines |
( ) Neurological Disorder |
Do you have any artificial joints? _______
If yes, which joints ______________
Do you have heart valve disease or valve replacement? ___________________
Family History:
|
Mother Living ______ |
Deceased _______ |
Cause of death ____________________ |
|
Father Living ______ |
Deceased _______ |
Cause of death ____________________ |
|
Brother Living ______ |
Deceased _______ |
Cause of death ____________________ |
|
Sister Living ______ |
Deceased _______ |
Cause of death ____________________ |
Is there a family (blood relative) history of :
|
( ) Heart Disease |
( ) Arthritis |
( ) Bleeding Disorder |
|
( ) Neurological Disorder |
( ) Stroke |
( ) Bunions |
|
( ) Hammertoes |
( ) Flatfeet |
( ) Circulation problems of the legs or feet |
Do you smoke? No___Yes ___ #packs per
day ____
Previously smoked? No___Yes ____ # of years ____
Do you drink alcohol or beer? Yes ___ No ____
If yes, number of drinks per day? ___ per week ____ per month ___
Employment: ( ) Sits at work ( ) Stands at job ( ) Stands and walks
at job ( ) Retired
Signature
_______________________________ Date ___________
