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PATIENT NAME: _____________________________ DATE OF BIRTH: ____/____/_____
Revised June 2015
PATIENTINFORMATIONFORM(PLEASEPRINT)
DATE:____/_____/_____PATIENTNAME:______________________________________DATEOFBIRTH:____/____/____AGE:____SEX:MF LAST FIRST MI
HOMEADDRESS:______________________________________ CITY/STATE:________________________ZIP:_____________
MAYWELEAVEAMESSAGE?HOMEPHONE#: (_____)_____-________ YESNO WORKPHONE#: (_____)_____-________ YESNO
CELLPHONE#: (_____)_____-________ YESNO
E-MAIL:_____________________________________ YESNO
PRIMARYLANGUAGE:__________________________RACE:___________________________________________ ETHNICITY:____________________________________
DOYOUHAVEALEGALGUARDIANORHEALTHCAREPOWEROFATTORNEY?YESNO IFYES,NAME:____________________________RELATIONSHIP:_____________PHONE#:(_____)_____-_______
EMERGENCYCONTACT:____________________________RELATIONSHIP:_____________PHONE#:(_____)_____-_______
PRIMARYCAREDOCTOR:___________________________________________PHONE:__________________________________PHARMACY:_____________________________LOCATION:__________________________PHONE#:(_____)_____-_______
ISTHEREAFAMILYMEMBEROROTHERPERSONYOUWOULDLIKEFORUSTOSHAREYOURMEDICALINFORMATION?NO______YES_____NAME(S)___________________________________________________________________________________
WHOISGUARANTORFORPAYMENT?______________________DOB:__________RELATIONSHIPTOPATIENT?__________
ADDRESS:________________________CITY/STATE:_________________ZIP:_________PHONE#:(_____)_____-______HOWDIDYOUHEARABOUTOUROFFICE?________________________________________________________________________INSURANCEINFORMATION
PRIMARYINSURANCECOMPANYNAME:_________________________________________________________________________
ADDRESS:________________________CITY/STATE:_________________ZIP:_________PHONE#:(_____)_____-______
INSUREDNAME:__________________________DATEOFBIRTH______________EMPLOYER___________________________
CONTRACT#__________________GROUP#____________________SECONDARYINSURANCECOMPANYNAME:_______________________________________________________________________
ADDRESS:________________________CITY/STATE:_________________ZIP:_________PHONE#:(_____)_____-______
INSUREDNAME:__________________________DATEOFBIRTH______________EMPLOYER___________________________
CONTRACT#__________________GROUP#____________________
PATIENT NAME: _____________________________ DATE OF BIRTH: ____/____/_____
Revised June 2015
PLEASELISTALLMEDICATIONSYOUARECURRENTLYTAKING(INCLUDEPRESCRIPTIONS,OVER-THE-COUNTERMEDSANDHERBALSUPPLEMENTS):NAME DOSE HOWOFTENDOYOUTAKE?_______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PLEASELISTALLPRIORSURGERIES:TYPEOFSURGERY DATE TYPEOFSURGERY DATE__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________PLEASELISTALLPRIORHOSPITALIZATIONS(OTHERTHANFORSURGERY):REASONFORHOSPITALIZATION DATE REASONFORHOSPITALIZATION DATE__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________IMMUNIZATION/DATEOFADMINISTRATIONINFLUENZA:________________________________________________________________________________________________PNEUMONIA:__________________________________________________________________________________________________SOCIALHISTORYMARITALSTATUS:cSINGLEcMARRIEDcPARTNEREDcSEPARATEDcDIVORCEDcWIDOWED
USEOFALCOHOL:cNEVERcNOLONGERUSEcHISTORYOFALCOHOLABUSEcCURRENTUSE-TYPE__________________cRAREcOCCASIONALcMODERATEcDAILY
USEOFTOBACCO:cNEVERcQUIT–HOWLONGAGO?_________cSMOKE____PACKS/DAYFOR____YEARS
USEOFRECREATIONALDRUGS:cNEVERcQUIT–HOWLONGAGO?_________TYPE_______________________
cCURRENTUSE-TYPE_______________cRAREcOCCASIONALcMODERATEcDAILY
EMPLOYER:_______________________________________OCCUPATION:____________________________________________
HOWMUCHAREYOUONYOURFEETATWORK?c10%c25%c50%c75%c100%
TYPESOFSHOESFORWORK/PLAY:____________________________________________________________________________TYPESOFSHOESFORHOME:__________________________________________________DOYOUGOBAREFOOTED:YN
EXERCISE:cNEVERcRAREcOCCASIONALcWEEKLYcSEVERALTIMESAWEEKcDAILY
TYPESOFEXERCISE:_____________________________________________________________________________________
PATIENT NAME: _____________________________ DATE OF BIRTH: ____/____/_____
Revised June 2015
FAMILYHISTORYDOYOUHAVEAFAMILYHISTORYOF:cDIABETES:TYPE1ORTYPE2cCANCER_________cHEARTDISEASEcHIGHBLOODPRESSUREcSTROKEcCORONARYARTERYDISEASEcTHYROIDDISEASEcRHEUMATOIDARTHRITIScOTHER_____________________________________________________________________YOURMEDICALHISTORY:HEIGHT:___________________WEIGHT:________________________ALLERGIES:cMEDICATIONS__________________________________cNONEKNOWN
cANESTHESIA_________________________________cFOODS____________________________________cTAPEcLATEXcSHELLFISHcIODINEcOTHER_______________________________________
HAVEYOUEVERHADANYOFTHEFOLLOWING?ACIDREFLUX Y N FIBROMYALGIA Y N NEUROPATHY Y NANEMIA Y N GOUT Y N PACEMAKER Y NARTHRITIS Y N HEARTATTACK Y N PNEUMONIA Y NASTHMA Y N HEARTDISEASE/FAILURE Y N POLIO Y NBACKTROUBLE Y N HEPATITIS Y N REFLUX/GERD Y NBLADDERINFECTIONS Y N HIV+/AIDS Y N SICKLECELLDISEASE Y NABNORMALBLEEDING Y N HIGHBLOODPRESSURE Y N SKINDISORDER Y NBLOODCLOTS/FILTER Y N KIDNEYDISEASE Y N SLEEPAPNEA Y NBLOODTRANSFUSIONBLEEDINGDISORDERS
YY
NN
LIVERDISEASELOWBLOODPRESSURE
YY
NN
STOMACHULCERS/IBSCROHN’S
YY
NN
BRONCHITIS/EMPHYSEMA Y N JOINTREPLACEMENTS Y N SEIZURESSTROKE
YY
NN
CANCERTYPE: Y N MIGRAINEHEADACHES Y N THYROIDDISEASE Y NDIABETES:TYPE1ORTYPE2(CIRCLE)
Y N MITRALVALVEPROLAPSE
Y N TUBERCULOSIS Y N
OTHERCONDITIONS:
CURRENTPROBLEMWHATSPECIFICPROBLEMBRINGSYOUTOOUROFFICETODAY?__________________________________________________
WHEREISTHEPAIN/PROBLEMLOCATED?PLEASEMARKONTHEPICTURESBELOW. LEFTFOOT RIGHTFOOT
INSIDEOFFOOTOUTSIDEOFFOOTOUTSIDEOFFOOTINSIDEOFFOOT
TOPOFFOOTBOTTOMOFFOOTBOTTOMOFFOOTTOPOFFOOT
PATIENT NAME: _____________________________ DATE OF BIRTH: ____/____/_____
Revised June 2015
HOWLONGAGODIDTHISPROBLEMFIRSTSTART?__________DAYS/WEEKS/MONTHS/YEARS
DIDYOURPAINORPROBLEM:cBEGINALLOFASUDDEN cGRADUALLYDEVELOPOVERTIME
HOWWOULDYOUDESCRIBEYOURPAIN?cNOPAINcSHARPcDULLcACHINGcBURNINGcRADIATINGcITCHINGcSTABBINGcOTHER________________________________________________
HOWWOULDYOURATEYOURPAINONASCALEFROM0TO10?(PLEASECIRCLE)(NOPAIN)012345678910(WORSTPAINPOSSIBLE)
SINCETHETIMEYOURPAINORPROBLEMBEGAN,HASIT:cSTAYEDTHESAMEcBECOMEWORSEcIMPROVED
WHATMAKESYOURPAINORPROBLEMFEELWORSE?cWALKINGcSTANDINGcDAILYACTIVITIEScRESTINGcDRESSSHOEScHIGHHEELScFLATSHOEScANYCLOSEDTOESHOEcRUNNINGcOTHER________________________________________________________________________________
WHATMAKESYOURPAINORPROBLEMFEELBETTER?____________________________________________________________
WHATTREATMENTSHAVEYOUHADFORTHISPROBLEM?_________________________________________________________
HOWHASTHISPROBLEMAFFECTEDYOURLIFESTYLEORABILITYTOWORK?_______________________________________
WASTHISPROBLEMCAUSEDBYANINJURY?cYES(DESCRIBE)_________________________________________cNO
IFYES:WORKAUTOOTHERINJURY____________________
CLAIM#________________________________WHEREWASITFILED_______________________________________TOTHEBESTOFMYKNOWLEDGE,IHAVEANSWEREDTHEQUESTIONSONTHISFORMACCURATELY.IUNDERSTANDTHATPROVIDINGINCORRECTINFORMATIONCANBEDANGEROUSTOMYHEALTH.IUNDERSTANDTHATITISMYRESPONSIBILITYTOINFORMTHEDOCTORANDOFFICESTAFFOFANYCHANGESINMYMEDICALSTATUS.___________________________________________________ ___________________________________________________PRINTNAMEOFPATIENT,PARENTORGUARDIAN SIGNATUREOFDOCTOR___________________________________________________ ___________________________________________________IFOTHERTHANPATIENT,RELATIONSHIPTOPATIENT DATE____________________________________________________SIGNATURE_____________________________________________DATE